Provider Demographics
NPI:1750623864
Name:THOMAS, MICHELLE (OT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:THOMAS
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 1:716 LEESVILLE RD APT 704
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-3839
Mailing Address - Country:US
Mailing Address - Phone:800-796-0923
Mailing Address - Fax:
Practice Address - Street 1:25 PINE CONE DR STE 4
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8424
Practice Address - Country:US
Practice Address - Phone:800-796-0923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004539225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist