Provider Demographics
NPI:1275901332
Name:LEWIS, MICHELLE RAE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W LA JOLLA DR APT 2120
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-4469
Mailing Address - Country:US
Mailing Address - Phone:262-995-3498
Mailing Address - Fax:
Practice Address - Street 1:1600 W LA JOLLA DR APT 2120
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-4469
Practice Address - Country:US
Practice Address - Phone:262-995-3498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-07
Last Update Date:2015-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ345297224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant