Provider Demographics
NPI:1508921990
Name:GOOD, MICHELLE ANN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN
Last Name:GOOD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:SHELLY
Other - Middle Name:ANN
Other - Last Name:GOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:409 WHITEFIELD AVE.
Mailing Address - Street 2:
Mailing Address - City:ST. SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522
Mailing Address - Country:US
Mailing Address - Phone:912-222-7413
Mailing Address - Fax:
Practice Address - Street 1:2601 DEMERE RD
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-1614
Practice Address - Country:US
Practice Address - Phone:912-634-9945
Practice Address - Fax:912-638-1584
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002198225XH1200X
GAOT002198225XH1200X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA67BBBKNMedicare UPIN
GA67BBBKHMedicare ID - Type Unspecified