=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831757830
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE WELLS OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2019
-----------------------------------------------------
Last Update Date | 06/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1764 MARCO POLO WAY
-----------------------------------------------------
City | BURLINGAME
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94010-4503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-906-0870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1080 SUTTER ST APT 403
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94109-5893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-906-3255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 19885
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------