Provider Demographics
NPI:1063797181
Name:ALLEN, MICHELLE DENISE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DENISE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1299 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-2007
Mailing Address - Country:US
Mailing Address - Phone:516-286-9246
Mailing Address - Fax:
Practice Address - Street 1:3415 W SANTIAGO ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-7977
Practice Address - Country:US
Practice Address - Phone:516-286-9246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19952235Z00000X
COSLP.0002176235Z00000X
NY023364235Z00000X
FLSA16340235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101436400Medicaid