Provider Demographics
NPI:1356800213
Name:LAVIOLETTE, MICHELLE MARIE (COTAL)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:LAVIOLETTE
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:LAVIOLETTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTAL
Mailing Address - Street 1:4127 CUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2725
Mailing Address - Country:US
Mailing Address - Phone:810-399-8613
Mailing Address - Fax:
Practice Address - Street 1:2701 CHESTNUT STATION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6395
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008478224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant