Provider Demographics
NPI:1528201829
Name:MOFFETT, MICHELLE L (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 NE 14TH CT APT 40
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-5694
Mailing Address - Country:US
Mailing Address - Phone:772-209-0076
Mailing Address - Fax:
Practice Address - Street 1:1451 NE 14TH CT APT 40
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-5694
Practice Address - Country:US
Practice Address - Phone:772-763-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT072-0000596225X00000X
MA09893225X00000X
FL7227225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist