Provider Demographics
NPI:1174042170
Name:MATHEW, MICHELLE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MATHEW
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 1:1638 LUPIN CT
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-9136
Mailing Address - Country:US
Mailing Address - Phone:209-679-6029
Mailing Address - Fax:
Practice Address - Street 1:1731 BUNKER HILL RD NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-3026
Practice Address - Country:US
Practice Address - Phone:202-832-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOT200001296225X00000X
CA17165225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist