Healthcare Provider Details

I. General information

NPI: 1730818097
Provider Name (Legal Business Name): DESIRAE MICHAELSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W WILLIAMS ST UNIT 346
APEX NC
27502-1998
US

IV. Provider business mailing address

261 WILDCAT BRANCH WAY APT 319
RALEIGH NC
27603-7617
US

V. Phone/Fax

Practice location:
  • Phone: 919-448-6018
  • Fax:
Mailing address:
  • Phone: 272-207-8571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number23227
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number17632
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier17623
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerNC LICENSE
# 2
Identifier114506300
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: