Healthcare Provider Details

I. General information

NPI: 1407489040
Provider Name (Legal Business Name): MICHELLE RANDALL MOTR-L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 BOSQUE FARMS BLVD
BOSQUE FARMS NM
87068-9652
US

IV. Provider business mailing address

2325 STEVENS DR NE
ALBUQUERQUE NM
87112-1449
US

V. Phone/Fax

Practice location:
  • Phone: 505-554-0052
  • Fax:
Mailing address:
  • Phone: 505-321-8217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: