Provider Demographics
NPI:1174915573
Name:ZULTAK, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ZULTAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1250 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-7074
Mailing Address - Country:US
Mailing Address - Phone:989-348-0314
Mailing Address - Fax:989-348-0549
Practice Address - Street 1:1250 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-7074
Practice Address - Country:US
Practice Address - Phone:989-348-0314
Practice Address - Fax:989-348-0549
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist