Provider Demographics
NPI:1306362512
Name:TESHOME, MICHELLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TESHOME
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:3510 TRAIL WEST DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9426
Mailing Address - Country:US
Mailing Address - Phone:630-303-2846
Mailing Address - Fax:
Practice Address - Street 1:1000 EDISON AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-3918
Practice Address - Country:US
Practice Address - Phone:630-303-2846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056012072225X00000X
MI5201010791225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist