Basic Information
| Provider Information | |||||||||
| NPI: | 1407076441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OUELLETTE | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1616 RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140929752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174471272 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27240 HAGGERTY RD | ||||||||
| Address2: | E-15 | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483315716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669910900 | ||||||||
| FaxNumber: | 8669920900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/12/2020 | ||||||||
| NPIReactivationDate: | 07/15/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 30386 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 70014579 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 21765 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.