Provider Demographics
NPI:1427522770
Name:DEJESUS, MICHELLE ROSANA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSANA
Last Name:DEJESUS
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 1:5541 NW 112TH AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4126
Mailing Address - Country:US
Mailing Address - Phone:352-328-1373
Mailing Address - Fax:
Practice Address - Street 1:7800 S RED RD STE 205
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-5542
Practice Address - Country:US
Practice Address - Phone:305-854-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19704225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics