Provider Demographics
NPI:1003433798
Name:ROBERTSON, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N TUSTIN AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3879
Mailing Address - Country:US
Mailing Address - Phone:714-617-4886
Mailing Address - Fax:
Practice Address - Street 1:400 N TUSTIN AVE STE 120
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3879
Practice Address - Country:US
Practice Address - Phone:714-617-4886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2025-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN689599164X00000X
225400000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner