Provider Demographics
NPI:1043529043
Name:GROSMAN-LIECHTUNG, MICHELLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GROSMAN-LIECHTUNG
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 E CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-2477
Mailing Address - Country:US
Mailing Address - Phone:516-208-5804
Mailing Address - Fax:516-232-8878
Practice Address - Street 1:540 E CHESTER ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-2477
Practice Address - Country:US
Practice Address - Phone:516-208-5804
Practice Address - Fax:516-232-8878
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-25
Last Update Date:2010-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017662235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist