Basic Information
| Provider Information | |||||||||
| NPI: | 1396090429 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SPEVAK | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | DW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 HUTCHINSON WOODS | ||||||||
| Address2: | |||||||||
| City: | FLETCHER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287328724 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 VANDERBILT PARK DR | ||||||||
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| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282131725 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2012 | ||||||||
| LastUpdateDate: | 07/15/2012 | ||||||||
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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 | 13374 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3400002 | 05 | NC | MEDICAID |