Provider Demographics
NPI:1407489040
Name:RANDALL, MICHELLE (MOTR-L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MOTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 STEVENS DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1449
Mailing Address - Country:US
Mailing Address - Phone:505-321-8217
Mailing Address - Fax:
Practice Address - Street 1:980 BOSQUE FARMS BLVD
Practice Address - Street 2:
Practice Address - City:BOSQUE FARMS
Practice Address - State:NM
Practice Address - Zip Code:87068-9652
Practice Address - Country:US
Practice Address - Phone:505-554-0052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1396354981Medicaid