Healthcare Provider Details

I. General information

NPI: 1386113074
Provider Name (Legal Business Name): MICHELLE W CICCANTELLI OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 11/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 TERRACE ST
MUSKEGON MI
49440-1220
US

IV. Provider business mailing address

608 WASHINGTON AVE
GRAND HAVEN MI
49417-1457
US

V. Phone/Fax

Practice location:
  • Phone: 231-672-4663
  • Fax: 231-672-4986
Mailing address:
  • Phone: 616-842-1075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201000613
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: