Provider Demographics
NPI:1730659087
Name:MUTOMBO, MICHELLE ROCCO-ANNE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ROCCO-ANNE
Last Name:MUTOMBO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:ROCCO-ANNE
Other - Last Name:LEGAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,CCC-SLP
Mailing Address - Street 1:1026 IRWINS CHOICE
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-2531
Mailing Address - Country:US
Mailing Address - Phone:443-567-2333
Mailing Address - Fax:
Practice Address - Street 1:2100 CONOWINGO RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-1843
Practice Address - Country:US
Practice Address - Phone:410-638-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05727235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
09147695OtherAMERICAN SPEECH LANGUAGE HEARING ASSOCIATION