Basic Information
| Provider Information | |||||||||
| NPI: | 1184286015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORMAN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | METTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | METTE | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5310 KIETZKE LN STE 104 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895112043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753488800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9990 DOUBLE R BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895214833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753488800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2019 | ||||||||
| LastUpdateDate: | 07/01/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3465 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 37229 | 01 | CA | CA LICENSE | OTHER | 3564 | 01 | NV | NV LICENSE | OTHER |