Provider Demographics
NPI:1750020327
Name:MANNINO, MICHELLE ANN (COTAL)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:MANNINO
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16121 26 MILE RD
Mailing Address - Street 2:
Mailing Address - City:RAY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48096-4003
Mailing Address - Country:US
Mailing Address - Phone:586-255-3494
Mailing Address - Fax:
Practice Address - Street 1:1775 S ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-3569
Practice Address - Country:US
Practice Address - Phone:248-923-5976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007866224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant