Provider Demographics
NPI:1558582528
Name:WAREHAM, MICHELLE L (ATC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:WAREHAM
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8564 MAJOR PL
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8444
Mailing Address - Country:US
Mailing Address - Phone:614-878-6838
Mailing Address - Fax:614-839-2141
Practice Address - Street 1:1313 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3129
Practice Address - Country:US
Practice Address - Phone:614-839-2140
Practice Address - Fax:614-839-2141
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-5802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer