Basic Information
| Provider Information | |||||||||
| NPI: | 1659434041 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZYGIELBAUM | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 FAIRMOUNT AVE STE 302 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109278768 | ||||||||
| FaxNumber: | 4106484878 | ||||||||
| Practice Location | |||||||||
| Address1: | 5411 W CEDAR LN | ||||||||
| Address2: | SUITE 105A | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208141516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015644040 | ||||||||
| FaxNumber: | 3015643604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 01/09/2018 | ||||||||
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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 | 19371 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 401490100 | 05 | MD | MEDICAID |