Provider Demographics
NPI:1144432170
Name:MICHAELI, CAROLYN MYRNA
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MYRNA
Last Name:MICHAELI
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 1:10 STEEPLETREE LN
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-3912
Mailing Address - Country:US
Mailing Address - Phone:508-358-7255
Mailing Address - Fax:
Practice Address - Street 1:10 STEEPLETREE LN
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-3912
Practice Address - Country:US
Practice Address - Phone:508-358-7255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA274224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0349682Medicaid
MAMI Y68812Medicare ID - Type Unspecified