Provider Demographics
NPI:1053872697
Name:FIREBAUGH, MICHELLE (MS, PT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FIREBAUGH
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1496 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-5961
Mailing Address - Country:US
Mailing Address - Phone:540-589-3126
Mailing Address - Fax:
Practice Address - Street 1:12970 BOOKER T WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:VA
Practice Address - Zip Code:24101-3953
Practice Address - Country:US
Practice Address - Phone:540-489-6368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004912225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist