Provider Demographics
NPI:1033569413
Name:COMPTON, MICHELLE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:COMPTON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BALLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:1515 N. LAKE HAVASU AVENUE
Mailing Address - Street 2:SUITE #100
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404
Mailing Address - Country:US
Mailing Address - Phone:928-854-5439
Mailing Address - Fax:928-854-5440
Practice Address - Street 1:2585 MIRACLE MILE ROAD
Practice Address - Street 2:UNIT #124
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442
Practice Address - Country:US
Practice Address - Phone:928-763-4030
Practice Address - Fax:928-854-5440
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
AZ6266224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6266OtherARIZONA STATE BOARD OF OCCUPATIONAL THERAPY