Provider Demographics
NPI:1578878286
Name:PINE, MICHELLE RENEE (LOTR)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:PINE
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 W TOM STOKES CT
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-3179
Mailing Address - Country:US
Mailing Address - Phone:225-278-1968
Mailing Address - Fax:
Practice Address - Street 1:932 W TOM STOKES CT
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-3179
Practice Address - Country:US
Practice Address - Phone:225-278-1968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200252225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist