Provider Demographics
NPI:1093160004
Name:FRASER, MICHELLE L (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:FRASER
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 1:103 COUNTRY GARDEN APTS
Mailing Address - Street 2:APT 2
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-6163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6141 STATE FARM RD
Practice Address - Street 2:
Practice Address - City:GUILDERLAND
Practice Address - State:NY
Practice Address - Zip Code:12084-9521
Practice Address - Country:US
Practice Address - Phone:518-724-7704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025719235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400310959Medicare PIN