Provider Demographics
NPI:1811272115
Name:TACKNOFF, MICHELLE H
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:H
Last Name:TACKNOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 ANGLESEY TER
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-2130
Mailing Address - Country:US
Mailing Address - Phone:215-990-6609
Mailing Address - Fax:
Practice Address - Street 1:411 ANGLESEY TER
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-2130
Practice Address - Country:US
Practice Address - Phone:215-990-6609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9970225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9970Medicaid
CA9970Medicaid