Healthcare Provider Details

I. General information

NPI: 1780912865
Provider Name (Legal Business Name): MICHELE NMN CHAMPION OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 OLD MEADOW RD SUITE 600
MC LEAN VA
22102-4311
US

IV. Provider business mailing address

917 W 20TH AVE
ANCHORAGE AK
99503-1712
US

V. Phone/Fax

Practice location:
  • Phone: 866-458-1088
  • Fax:
Mailing address:
  • Phone: 907-279-9217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number898
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number898
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number898
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: