Provider Demographics
NPI:1841597481
Name:TANNER, MICHELLE GAIL (OTR)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GAIL
Last Name:TANNER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:GAIL
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3705 MEDICAL PKWY
Mailing Address - Street 2:SUITE 515
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1019
Mailing Address - Country:US
Mailing Address - Phone:512-452-6475
Mailing Address - Fax:512-371-7051
Practice Address - Street 1:3705 MEDICAL PKWY
Practice Address - Street 2:SUITE 515
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1019
Practice Address - Country:US
Practice Address - Phone:512-452-6475
Practice Address - Fax:512-371-7051
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113990225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist