Provider Demographics
NPI:1114061611
Name:MAZUR, MICHELLE L (OT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:MAZUR
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNNE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 625
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-0625
Mailing Address - Country:US
Mailing Address - Phone:307-335-3471
Mailing Address - Fax:307-332-5388
Practice Address - Street 1:535 E MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3424
Practice Address - Country:US
Practice Address - Phone:307-335-3471
Practice Address - Fax:307-332-5388
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT814225XH1200X
WAOT00003155225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5245MAOtherREGENCE BLUE SHIELD
WA8950731OtherL&I CRIME
WA0218062OtherDEPT. OF LABOR & INDUSTRY
WA8950731OtherDSHS
WAG8880790Medicare UPIN
WAG8863835Medicare PIN