Provider Demographics
NPI:1619357076
Name:ADAMS, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ADAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 LADYS ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:PORT ROYAL
Mailing Address - State:SC
Mailing Address - Zip Code:29935-1106
Mailing Address - Country:US
Mailing Address - Phone:843-940-7053
Mailing Address - Fax:
Practice Address - Street 1:1251 LADYS ISLAND DR
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-1106
Practice Address - Country:US
Practice Address - Phone:843-940-7053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000117224Z00000X
SC3024224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant