Provider Demographics
NPI:1417074808
Name:KOTTLOWSKI, MICHELE (MS,OTR)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:KOTTLOWSKI
Suffix:
Gender:F
Credentials:MS,OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10882 FAIRWAY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3380 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-9089
Practice Address - Country:US
Practice Address - Phone:131-771-8008
Practice Address - Fax:131-771-8009
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000761A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN31000761AOtherOT PROFESSIONAL LICENSE