Basic Information
| Provider Information | |||||||||
| NPI: | 1790755619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SYDNOR | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTR/L, CHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3528 WADE AVENUE | ||||||||
| Address2: | #139 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276074048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197825954 | ||||||||
| FaxNumber: | 9198599444 | ||||||||
| Practice Location | |||||||||
| Address1: | 2418 BLUE RIDGE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276076480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197825954 | ||||||||
| FaxNumber: | 9198599444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 05/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0803 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5947795 | 01 | NC | AETNA | OTHER | D9649 | 01 | NC | MEDCOST | OTHER | 670002182 | 01 | NC | MEDICARE RAILROAD | OTHER | 81309 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |