Provider Demographics
NPI:1790755619
Name:SYDNOR, MICHELLE RENEE (OTR/L, CHT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENEE
Last Name:SYDNOR
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3528 WADE AVENUE
Mailing Address - Street 2:#139
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-4048
Mailing Address - Country:US
Mailing Address - Phone:919-782-5954
Mailing Address - Fax:919-859-9444
Practice Address - Street 1:2418 BLUE RIDGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6480
Practice Address - Country:US
Practice Address - Phone:919-782-5954
Practice Address - Fax:919-859-9444
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0803225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5947795OtherAETNA
NCD9649OtherMEDCOST
NC670002182OtherMEDICARE RAILROAD
NC81309OtherBLUE CROSS BLUE SHIELD
NCD9649OtherMEDCOST
NC5947795OtherAETNA