Provider Demographics
NPI:1053606913
Name:VICKERS, MICHELLE L (PTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:VICKERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1158 NATURE RUN RD
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-1040
Mailing Address - Country:US
Mailing Address - Phone:513-943-9220
Mailing Address - Fax:
Practice Address - Street 1:6915 BEECHMONT AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-2909
Practice Address - Country:US
Practice Address - Phone:513-232-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA04080225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist