Provider Demographics
NPI:1790144871
Name:VICKMAN, MICHELLE L (OT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:VICKMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9718 W TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-2997
Mailing Address - Country:US
Mailing Address - Phone:262-483-5072
Mailing Address - Fax:
Practice Address - Street 1:2 KEEWAYDIN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-2839
Practice Address - Country:US
Practice Address - Phone:800-995-2673
Practice Address - Fax:888-979-6551
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA075812225X00000X
IL056011092225X00000X
TX116567225X00000X
WI5535-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist