Provider Demographics
NPI:1083037840
Name:BURKHARD, MICHELLE NICOLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:BURKHARD
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:NICOLE
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA/L
Mailing Address - Street 1:12921 1ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98146-3302
Mailing Address - Country:US
Mailing Address - Phone:321-356-1636
Mailing Address - Fax:
Practice Address - Street 1:12921 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98146-3302
Practice Address - Country:US
Practice Address - Phone:321-356-1636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60178454224Z00000X
FLOTA9958224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant