Provider Demographics
NPI:1104278936
Name:SHAN, MICHELLE
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:SHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1049 E WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2474
Mailing Address - Country:US
Mailing Address - Phone:630-761-0900
Mailing Address - Fax:630-761-0909
Practice Address - Street 1:1049 E WILSON ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2474
Practice Address - Country:US
Practice Address - Phone:630-761-0900
Practice Address - Fax:630-761-0909
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.003934235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist