Provider Demographics
NPI:1699264325
Name:SCALLY, MICHELLE MARIE (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:SCALLY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 HERON CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-8766
Mailing Address - Country:US
Mailing Address - Phone:314-920-8937
Mailing Address - Fax:844-222-9314
Practice Address - Street 1:403 HERON CREEK DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-8766
Practice Address - Country:US
Practice Address - Phone:815-556-2711
Practice Address - Fax:844-222-9314
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL399099225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist