Basic Information
| Provider Information | |||||||||
| NPI: | 1104062637 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROUSE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | CANDICE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3455 HIGHWAY 81 | ||||||||
| Address2: | |||||||||
| City: | LOGANVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300529138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705540665 | ||||||||
| FaxNumber: | 7705540685 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 CHARLES H DIMMOCK PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238342986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045265888 | ||||||||
| FaxNumber: | 8045265401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2009 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT009848 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305205763 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00848311 | 01 | GA | MEDICARE RR | OTHER |