Provider Demographics
NPI:1740580497
Name:SANDWICK, MICHELLE (MS, OTR)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SANDWICK
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 LOOP DR # 821
Mailing Address - Street 2:SUITE 211-12
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-5017
Mailing Address - Country:US
Mailing Address - Phone:800-340-4098
Mailing Address - Fax:
Practice Address - Street 1:911 LOOP DR # 821
Practice Address - Street 2:SUITE 211-12
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-5017
Practice Address - Country:US
Practice Address - Phone:800-340-4098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113900225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX676535Medicare PIN
TX456606Medicare PIN