Provider Demographics
NPI:1750629374
Name:KOYAMA, MICHELLE LOUISE (MA OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LOUISE
Last Name:KOYAMA
Suffix:
Gender:F
Credentials:MA OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4306
Mailing Address - Country:US
Mailing Address - Phone:612-789-1236
Mailing Address - Fax:612-706-5555
Practice Address - Street 1:1800 2ND ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-4306
Practice Address - Country:US
Practice Address - Phone:612-789-1236
Practice Address - Fax:612-706-5555
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104344225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN104344OtherSTATE LICENSE