Provider Demographics
NPI:1467719153
Name:BRACKETT, MICHELLE R (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:R
Last Name:BRACKETT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 CASSENA CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23453-7066
Mailing Address - Country:US
Mailing Address - Phone:757-468-0155
Mailing Address - Fax:
Practice Address - Street 1:2924 CASSENA CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-7066
Practice Address - Country:US
Practice Address - Phone:757-468-0155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA232988224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant