Provider Demographics
NPI:1497295828
Name:STAAB, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:STAAB
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 1:102 DUNSFORD CT
Mailing Address - Street 2:
Mailing Address - City:WALKERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21793-8247
Mailing Address - Country:US
Mailing Address - Phone:240-446-2249
Mailing Address - Fax:
Practice Address - Street 1:102 DUNSFORD CT
Practice Address - Street 2:
Practice Address - City:WALKERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21793-8247
Practice Address - Country:US
Practice Address - Phone:240-446-2249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-04
Last Update Date:2017-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC2100224Z00000X
MDA02107224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant