Provider Demographics
NPI:1588893481
Name:MINTZ, MICHELLE (MS,CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MINTZ
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 1:1537 BERKELEY ST
Mailing Address - Street 2:#7
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1537 BERKELEY ST
Practice Address - Street 2:#7
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3224
Practice Address - Country:US
Practice Address - Phone:310-902-5008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CASP 9857235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner