Healthcare Provider Details

I. General information

NPI: 1508402942
Provider Name (Legal Business Name): MICHELLE TRIPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 E ARLINGTON BLVD STE A
GREENVILLE NC
27858-7850
US

IV. Provider business mailing address

5 REVERE DR STE 120
NORTHBROOK IL
60062-8005
US

V. Phone/Fax

Practice location:
  • Phone: 252-758-7048
  • Fax:
Mailing address:
  • Phone: 847-807-3717
  • Fax: 847-348-3706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2596
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: