Provider Demographics
NPI:1710664958
Name:WANEK, MICHELLE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WANEK
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 TELSTAR DR STE 160
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1043
Mailing Address - Country:US
Mailing Address - Phone:719-305-8274
Mailing Address - Fax:
Practice Address - Street 1:2375 TELSTAR DR STE 160
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1043
Practice Address - Country:US
Practice Address - Phone:719-305-8274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0008035225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist