Healthcare Provider Details

I. General information

NPI: 1174854871
Provider Name (Legal Business Name): MICHELLE LANCLOS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 LA SALLE AVE
SAINT CLOUD FL
34772-8037
US

IV. Provider business mailing address

3975 LA SALLE AVE
SAINT CLOUD FL
34772-8037
US

V. Phone/Fax

Practice location:
  • Phone: 407-892-9113
  • Fax:
Mailing address:
  • Phone: 407-892-9113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT7710
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: