Provider Demographics
NPI:1063644581
Name:GRODE, MICHELLE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GRODE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 N COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-6606
Mailing Address - Country:US
Mailing Address - Phone:605-366-8790
Mailing Address - Fax:
Practice Address - Street 1:2200 HAVASUPAI BLVD
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-3122
Practice Address - Country:US
Practice Address - Phone:605-366-8790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4391225X00000X
IL056.008353225X00000X
SD0784225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist