Basic Information
| Provider Information | |||||||||
| NPI: | 1710614938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMICHELE | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15410 S MOUNTAIN PKWY STE 112 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850446691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806895534 | ||||||||
| FaxNumber: | 4807067997 | ||||||||
| Practice Location | |||||||||
| Address1: | 1702 S VAL VISTA DR STE 107 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852047386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805058140 | ||||||||
| FaxNumber: | 4807067997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2022 | ||||||||
| LastUpdateDate: | 08/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | LPT-32427 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.