Provider Demographics
NPI:1417017112
Name:GOODER, MICHELLE ANN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN
Last Name:GOODER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 HIGHLANDER TRL
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7977
Mailing Address - Country:US
Mailing Address - Phone:715-386-1685
Mailing Address - Fax:
Practice Address - Street 1:210 N LOCKWOOD ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:WI
Practice Address - Zip Code:54028-9710
Practice Address - Country:US
Practice Address - Phone:715-698-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4063026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40880200Medicaid