Basic Information
| Provider Information | |||||||||
| NPI: | 1386113074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CICCANTELLI | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494171457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168421075 | ||||||||
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| Practice Location | |||||||||
| Address1: | 888 TERRACE ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494401220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316724663 | ||||||||
| FaxNumber: | 2316724986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2018 | ||||||||
| LastUpdateDate: | 11/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201000613 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.