Provider Demographics
NPI:1053585976
Name:DISHNER, MICHELLE LEA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEA
Last Name:DISHNER
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 1:2648 E MADISON DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30360-2027
Mailing Address - Country:US
Mailing Address - Phone:770-354-0883
Mailing Address - Fax:
Practice Address - Street 1:1070 HARDSCRABBLE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2204
Practice Address - Country:US
Practice Address - Phone:770-354-0883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003646225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT003646OtherSECRETARY OF STATE