Provider Demographics
NPI:1740487891
Name:MYERS, MICHELLE LEA (COTA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEA
Last Name:MYERS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2342 MEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46803-3127
Mailing Address - Country:US
Mailing Address - Phone:260-749-9074
Mailing Address - Fax:
Practice Address - Street 1:2827 NORTHGATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-2903
Practice Address - Country:US
Practice Address - Phone:260-492-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001209A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1555656Medicaid