Provider Demographics
NPI:1770190290
Name:SERBENT, MICHELLE ANN (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:SERBENT
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:KILLINGWORTH
Mailing Address - State:CT
Mailing Address - Zip Code:06419-1004
Mailing Address - Country:US
Mailing Address - Phone:860-759-4677
Mailing Address - Fax:
Practice Address - Street 1:4 COUNTY RD
Practice Address - Street 2:
Practice Address - City:KILLINGWORTH
Practice Address - State:CT
Practice Address - Zip Code:06419-1004
Practice Address - Country:US
Practice Address - Phone:860-759-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001629225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist