Provider Demographics
NPI:1114206596
Name:GUNN, MICHELLE RENEE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENEE
Last Name:GUNN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:RENEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:2714 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4138
Mailing Address - Country:US
Mailing Address - Phone:402-494-3440
Mailing Address - Fax:402-494-3441
Practice Address - Street 1:3501 DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-3641
Practice Address - Country:US
Practice Address - Phone:402-494-3440
Practice Address - Fax:402-494-3441
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE733224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant