Provider Demographics
NPI:1124336151
Name:THEODORE, MICHELLE M (BA)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:M
Last Name:THEODORE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 N. HARBOR CITY BLVD.
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-6527
Mailing Address - Country:US
Mailing Address - Phone:321-259-8928
Mailing Address - Fax:321-259-6060
Practice Address - Street 1:1495 N. HARBOR CITY BLVD.
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6527
Practice Address - Country:US
Practice Address - Phone:321-259-8928
Practice Address - Fax:321-259-6060
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000481600Medicaid