Provider Demographics
NPI:1992903066
Name:DERMODY, MICHELLE (COTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DERMODY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7506 KIL CT
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-3439
Mailing Address - Country:US
Mailing Address - Phone:219-864-8304
Mailing Address - Fax:
Practice Address - Street 1:901 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2901
Practice Address - Country:US
Practice Address - Phone:219-836-4527
Practice Address - Fax:219-836-6752
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000080A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN32000080AOtherCOTA