Provider Demographics
NPI:1003136219
Name:MICHAUD, CAROLYN (OTD OTR/L)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MICHAUD
Suffix:
Gender:F
Credentials:OTD OTR/L
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:PAKUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3830 S CUSHMAN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7530
Mailing Address - Country:US
Mailing Address - Phone:907-452-1575
Mailing Address - Fax:
Practice Address - Street 1:4325 LAUREL ST STE 102
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5364
Practice Address - Country:US
Practice Address - Phone:907-569-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AK137212225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0157Medicaid
AKK0000WCHCPMedicare PIN