Provider Demographics
NPI:1366777062
Name:VICENTE, MICHELLE MARIE
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:MARIE
Last Name:VICENTE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:VICENTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMT
Mailing Address - Street 1:231 W 10TH ST
Mailing Address - Street 2:STE. B
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3931
Mailing Address - Country:US
Mailing Address - Phone:209-204-4376
Mailing Address - Fax:
Practice Address - Street 1:231 W 10TH ST
Practice Address - Street 2:STE. B
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3931
Practice Address - Country:US
Practice Address - Phone:209-204-4376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist