Provider Demographics
NPI:1770933756
Name:BRANNON, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BRANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DT
Mailing Address - Street 1:1045 177TH PL
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46324-3036
Mailing Address - Country:US
Mailing Address - Phone:219-629-4209
Mailing Address - Fax:
Practice Address - Street 1:1045 177TH PL
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46324-3036
Practice Address - Country:US
Practice Address - Phone:219-629-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist