MEDICARE: MICHELLE TESHOME OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056012072	IL
2	225X00000X	Occupational Therapist	5201010791	MI

General Provider Information

NPI Number	:	1306362512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE TESHOME OTR/L

Provider Business Mailing Address
First Line	:	3510 TRAIL WEST DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9426
Country	:	US
Telephone Number	:	630-303-2846
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 EDISON AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-3918
Country	:	US
Telephone Number	:	630-303-2846
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2017
Last Update Date	:	06/01/2023

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