Provider Demographics
NPI:1043385834
Name:SAMUELSON, MICHELLE MARIE
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MAIN AVE S
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1518
Mailing Address - Country:US
Mailing Address - Phone:218-732-0868
Mailing Address - Fax:218-732-8502
Practice Address - Street 1:200 MAIN AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1518
Practice Address - Country:US
Practice Address - Phone:218-732-0868
Practice Address - Fax:218-732-8502
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102954225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN13K2THOtherBLUE CROSS IND ID #
MN64-04244OtherMEDICA ID #
MN64-04244OtherMEDICA ID #