Provider Demographics
NPI:1053993493
Name:MOREAU, MICHELLE (MS ATC/LAT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MOREAU
Suffix:
Gender:F
Credentials:MS ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 FOREST HILLS DR
Mailing Address - Street 2:
Mailing Address - City:LURAY
Mailing Address - State:VA
Mailing Address - Zip Code:22835-9106
Mailing Address - Country:US
Mailing Address - Phone:802-324-3233
Mailing Address - Fax:
Practice Address - Street 1:18952 E FISHER RD
Practice Address - Street 2:
Practice Address - City:ST MARYS CITY
Practice Address - State:MD
Practice Address - Zip Code:20686
Practice Address - Country:US
Practice Address - Phone:240-895-4417
Practice Address - Fax:240-895-4480
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00010042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer