Provider Demographics
NPI:1245417948
Name:MADDRELL, MICHELLE LYN (LAC AND OTL)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYN
Last Name:MADDRELL
Suffix:
Gender:F
Credentials:LAC AND OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 SE 170TH CT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8800
Mailing Address - Country:US
Mailing Address - Phone:360-852-8148
Mailing Address - Fax:
Practice Address - Street 1:8507 NE 8TH WAY
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1980
Practice Address - Country:US
Practice Address - Phone:360-254-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3061171100000X
WA3007225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171100000XOther Service ProvidersAcupuncturist