MEDICARE: MICHELLE J LEE MOT, 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	13040	CA
2	225X00000X	Occupational Therapist	80845784201	UT

General Provider Information

NPI Number	:	1518203934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE J LEE MOT, OTR/L

Provider Business Mailing Address
First Line	:	8375 S RIDGE POINT RD
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-1088
Country	:	US
Telephone Number	:	801-244-4659
Fax Number	:

Provider Business Practice Location Address
First Line	:	5310 FOUNTAIN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1005
Country	:	US
Telephone Number	:	323-461-9961
Fax Number	:

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

Provider Enumeration Date	:	12/13/2012
Last Update Date	:	12/13/2012

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