Provider Demographics
NPI:1407076441
Name:OUELLETTE, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:OUELLETTE
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 1:1616 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-9752
Mailing Address - Country:US
Mailing Address - Phone:617-447-1272
Mailing Address - Fax:
Practice Address - Street 1:27240 HAGGERTY RD
Practice Address - Street 2:E-15
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-5716
Practice Address - Country:US
Practice Address - Phone:866-991-0900
Practice Address - Fax:866-992-0900
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2020-07-15
Deactivation Date:2020-05-12
Deactivation Code:
Reactivation Date:2020-07-15
Provider Licenses
StateLicense IDTaxonomies
CA30386225100000X
IL70014579225100000X
MD21765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist