Provider Demographics
NPI:1194096511
Name:MEDVED, MICHAELA A
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:A
Last Name:MEDVED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 W 104TH ST
Mailing Address - Street 2:APTARTMENT 4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-4150
Mailing Address - Country:US
Mailing Address - Phone:201-658-1434
Mailing Address - Fax:
Practice Address - Street 1:318 W 104TH ST
Practice Address - Street 2:APTARTMENT 4
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-4150
Practice Address - Country:US
Practice Address - Phone:201-658-1434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist