Provider Demographics
NPI:1164208153
Name:REID, MICHAELA CAROLYN
Entity Type:Individual
Prefix:MS
First Name:MICHAELA
Middle Name:CAROLYN
Last Name:REID
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 1:2236 CRESCENT CIR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9515
Mailing Address - Country:US
Mailing Address - Phone:909-213-9911
Mailing Address - Fax:
Practice Address - Street 1:2236 CRESCENT CIR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-9515
Practice Address - Country:US
Practice Address - Phone:909-213-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT23515225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist