Provider Demographics
NPI:1255321246
Name:BJORNSON, MICHELLE L (OT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:BJORNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W GEORGIA AVE
Mailing Address - Street 2:STE 115
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6811
Mailing Address - Country:US
Mailing Address - Phone:208-463-3234
Mailing Address - Fax:208-463-3044
Practice Address - Street 1:4400 E FLAMINGO AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9203
Practice Address - Country:US
Practice Address - Phone:208-288-4970
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT558225X00000X
MD1020367225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010150172OtherBLUE SHIELD
IDW1028OtherBLUE CROSS
IDP00218129OtherRAILROAD MEDICARE
1654116Medicare PIN