Provider Demographics
NPI:1306174354
Name:MICKELSON, ASHLEY MARIE (SLP)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:318-675-6262
Mailing Address - Fax:
Practice Address - Street 1:889 GORDON RD
Practice Address - Street 2:
Practice Address - City:WHITEWRIGHT
Practice Address - State:TX
Practice Address - Zip Code:75491-7102
Practice Address - Country:US
Practice Address - Phone:903-926-8456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-302053174N00000X
LA6440235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3C921F600OtherMEDICARE - PTAN
LA2075645Medicaid