Provider Demographics
NPI:1376920058
Name:HEDGE, MICHELLE ANN YTAC
Entity Type:Individual
Prefix:
First Name:MICHELLE ANN
Middle Name:YTAC
Last Name:HEDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 FIANNA WAY
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72919-0001
Mailing Address - Country:US
Mailing Address - Phone:479-201-4835
Mailing Address - Fax:
Practice Address - Street 1:16170 KINGSPORT RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5602
Practice Address - Country:US
Practice Address - Phone:708-326-1550
Practice Address - Fax:708-326-1557
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3880225X00000X, 225XG0600X
IL056008720225XG0600X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1346420015Medicaid