Provider Demographics
NPI:1437482502
Name:MINTZ, MICHELLE POTOCSKY (OTL)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:POTOCSKY
Last Name:MINTZ
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2371 HIDDEN LAKE CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-3303
Mailing Address - Country:US
Mailing Address - Phone:248-363-5631
Mailing Address - Fax:
Practice Address - Street 1:5640 W MAPLE RD STE 204
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3718
Practice Address - Country:US
Practice Address - Phone:248-318-6654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002607225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist