Provider Demographics
NPI:1104100080
Name:SLADEK, MICHELLE LORRAINE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LORRAINE
Last Name:SLADEK
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 1:646 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2738
Mailing Address - Country:US
Mailing Address - Phone:480-577-8332
Mailing Address - Fax:
Practice Address - Street 1:1221 W WARNER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-1906
Practice Address - Country:US
Practice Address - Phone:480-735-0124
Practice Address - Fax:480-735-0126
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0764225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ922783Medicaid
AZ102214Medicare PIN