=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679282255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE STAWIARSKI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2022
-----------------------------------------------------
Last Update Date | 11/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20311 PEMBERVILLE RD
-----------------------------------------------------
City | PEMBERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43450-9413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-923-9078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 TRAFALGAR BND
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43402-9380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-308-1824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OTA.06218
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------