Provider Demographics
NPI:1902212475
Name:CLEVINGER, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CLEVINGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 MEMORIAL AVE SW APT 93
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-1916
Mailing Address - Country:US
Mailing Address - Phone:540-598-6960
Mailing Address - Fax:
Practice Address - Street 1:2001 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7126
Practice Address - Country:US
Practice Address - Phone:540-387-4945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-06
Last Update Date:2014-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601271225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant