Provider Demographics
NPI:1033993605
Name:MICHAEL, MADALYN
Entity Type:Individual
Prefix:
First Name:MADALYN
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 MORGAN WAY
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-4106
Mailing Address - Country:US
Mailing Address - Phone:314-520-3127
Mailing Address - Fax:
Practice Address - Street 1:2824 SECKMAN RD
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-1941
Practice Address - Country:US
Practice Address - Phone:636-296-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023033488235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist