Healthcare Provider Details

I. General information

NPI: 1336269760
Provider Name (Legal Business Name): MICHELLE GAETA OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9880 ANGIES WAY STE 100
LOUISVILLE KY
40241-2851
US

IV. Provider business mailing address

3175 CLORE JACKSON RD
SHELBYVILLE KY
40065-9078
US

V. Phone/Fax

Practice location:
  • Phone: 502-339-6490
  • Fax:
Mailing address:
  • Phone: 732-796-3257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number174429
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT-10219
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: