Provider Demographics
NPI:1346390770
Name:O'CONNOR, MICHELLE ANN (OTD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ANN
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:ANN
Other - Last Name:GANGITANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10300 GOLF COURSE RD NW
Mailing Address - Street 2:#1217
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3917
Mailing Address - Country:US
Mailing Address - Phone:505-934-1932
Mailing Address - Fax:
Practice Address - Street 1:401 N 2ND ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2507
Practice Address - Country:US
Practice Address - Phone:505-285-2614
Practice Address - Fax:505-287-8487
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2295225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22473351Medicaid