Provider Demographics
NPI:1013210954
Name:HUMANN, MICHELLE AUDREY
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:AUDREY
Last Name:HUMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:AUDREY
Other - Last Name:MIRRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3224 CORPORAL KENNEDY ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1061
Mailing Address - Country:US
Mailing Address - Phone:718-229-7600
Mailing Address - Fax:
Practice Address - Street 1:3224 CORPORAL KENNEDY ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1061
Practice Address - Country:US
Practice Address - Phone:718-229-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020670235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist