Provider Demographics
NPI:1538453147
Name:HUSKAMP, MICHELLE (PT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HUSKAMP
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 STONE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-3322
Mailing Address - Country:US
Mailing Address - Phone:864-354-4621
Mailing Address - Fax:
Practice Address - Street 1:105 STONE CREEK RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-3322
Practice Address - Country:US
Practice Address - Phone:864-354-4621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2074174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0990Medicaid