Provider Demographics
NPI:1669214862
Name:TISON, MICHELE LEE (COTA/L, CLT-LANA)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:LEE
Last Name:TISON
Suffix:
Gender:F
Credentials:COTA/L, CLT-LANA
Other - Prefix:MRS
Other - First Name:MICHELE
Other - Middle Name:LEE
Other - Last Name:TISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L, CLT-LANA
Mailing Address - Street 1:1104 W HIAWATHA ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-6413
Mailing Address - Country:US
Mailing Address - Phone:813-743-1390
Mailing Address - Fax:
Practice Address - Street 1:1104 W HIAWATHA ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-6413
Practice Address - Country:US
Practice Address - Phone:813-743-1390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA8904224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant