Provider Demographics
NPI:1538385844
Name:STACH, MICHELLE CATHERINE (PTAL)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CATHERINE
Last Name:STACH
Suffix:
Gender:F
Credentials:PTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3592 207TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520-9464
Mailing Address - Country:US
Mailing Address - Phone:218-643-1469
Mailing Address - Fax:
Practice Address - Street 1:1307 4 AVE NORTH
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075
Practice Address - Country:US
Practice Address - Phone:701-642-6667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND655225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant