MEDICARE: MICHELLE THORSTAD RBT

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	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16-16835	OTHER		TRICARE

General Provider Information

NPI Number	:	1396254801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE THORSTAD RBT

Provider Business Mailing Address
First Line	:	247 BEACH WALK
Second Line	:	203
City	:	HONOLULU
State	:	HI
Zip	:	96815-1995
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	247 BEACH WALK
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96815-1995
Country	:	US
Telephone Number	:	312-560-8793
Fax Number	:

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

Provider Enumeration Date	:	09/27/2017
Last Update Date	:	06/11/2019

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Directions to “ MICHELLE THORSTAD RBT” Practice Location

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