Provider Demographics
NPI:1487395208
Name:PRENTICE, MICHAEL ERIC (CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ERIC
Last Name:PRENTICE
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 MARINA LAKES DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-7448
Mailing Address - Country:US
Mailing Address - Phone:510-372-6671
Mailing Address - Fax:
Practice Address - Street 1:645 TAMALPAIS DR STE B
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1613
Practice Address - Country:US
Practice Address - Phone:415-924-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16601235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist