Provider Demographics
NPI:1700153111
Name:MARTIN, MICHELLE L (OT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:VAN GORDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:3311 BAYSHORE BLVD NE FL 33703
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-5507
Mailing Address - Country:US
Mailing Address - Phone:239-560-9663
Mailing Address - Fax:
Practice Address - Street 1:3311 BAYSHORE BLVD NE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-5507
Practice Address - Country:US
Practice Address - Phone:239-560-9663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9896225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist