Provider Demographics
NPI:1174138804
Name:PHAN, MYCHELLE (PT, DPT, OCS)
Entity type:Individual
Prefix:
First Name:MYCHELLE
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51ST MEDICAL GROUP
Mailing Address - Street 2:UNIT 2060
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96278-2060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51ST MEDICAL GROUP
Practice Address - Street 2:UNIT 2060
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96278-2060
Practice Address - Country:US
Practice Address - Phone:315-784-2157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1330509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist