Provider Demographics
NPI:1194091405
Name:EVANS, MICHELLE J (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:EVANS
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 1:1700 RACHEL TER APT 14
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9305
Mailing Address - Country:US
Mailing Address - Phone:973-412-5990
Mailing Address - Fax:
Practice Address - Street 1:1700 RACHEL TER APT 14
Practice Address - Street 2:
Practice Address - City:PINE BROOK
Practice Address - State:NJ
Practice Address - Zip Code:07058-9305
Practice Address - Country:US
Practice Address - Phone:973-412-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00491500235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist