Provider Demographics
NPI:1558797308
Name:PROVOLT, MICHELLE RENEE (OTR)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:PROVOLT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8531 W 86TH CIR
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80005-1517
Mailing Address - Country:US
Mailing Address - Phone:847-477-0860
Mailing Address - Fax:
Practice Address - Street 1:1829 DENVER WEST DR
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-3120
Practice Address - Country:US
Practice Address - Phone:303-982-7276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225X00000X
NV13-0360225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17185033Medicaid