Provider Demographics
NPI:1336987726
Name:VACHA, MADISSEN ANNE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MADISSEN
Middle Name:ANNE
Last Name:VACHA
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 1:2450 44TH ST SE STE 201
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9081
Mailing Address - Country:US
Mailing Address - Phone:616-528-0870
Mailing Address - Fax:616-591-5684
Practice Address - Street 1:2450 44TH ST SE STE 201
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-9081
Practice Address - Country:US
Practice Address - Phone:616-528-0870
Practice Address - Fax:616-591-5684
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MI7101008711235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist