Provider Demographics
NPI:1972970366
Name:MATHIS, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2923 E LEE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-1786
Mailing Address - Country:US
Mailing Address - Phone:703-717-7659
Mailing Address - Fax:703-717-7660
Practice Address - Street 1:2923 E LEE AVE STE C
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-1786
Practice Address - Country:US
Practice Address - Phone:703-717-7659
Practice Address - Fax:703-717-7660
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL31922255A2300X
VA2305209814225100000X
DCPT871883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer