Provider Demographics
NPI:1538695242
Name:BRYANT, MICHELLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 DAVIS DR
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2242
Mailing Address - Country:US
Mailing Address - Phone:417-256-0798
Mailing Address - Fax:417-256-3996
Practice Address - Street 1:211 DAVIS DR
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2242
Practice Address - Country:US
Practice Address - Phone:417-256-0798
Practice Address - Fax:417-256-3996
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017012414224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO224Z00000XMedicaid