Provider Demographics
NPI:1730291220
Name:BREITBACH, MICHELLE (PT)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:BREITBACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:DEMAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:850 43RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:112 2ND ST NW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2619
Practice Address - Country:US
Practice Address - Phone:319-352-0102
Practice Address - Fax:319-352-0104
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27252225100000X
IA004823225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist