Provider Demographics
NPI:1104024033
Name:MURDOCK, MICHAEL J (MS CCC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MURDOCK
Suffix:
Gender:M
Credentials:MS CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 BUENA VISTA DR
Mailing Address - Street 2:PO BOX 202
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3463
Mailing Address - Country:US
Mailing Address - Phone:307-349-2998
Mailing Address - Fax:
Practice Address - Street 1:1425 BUENA VISTA DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3463
Practice Address - Country:US
Practice Address - Phone:307-349-2998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY074235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01028456OtherASHA CERTIFICATION
WY074OtherSTATE LICENSURE
WY074OtherWYOMING SPEECH AND HEARING ASSOCIATION
CO2226OtherCOLORADO SPEECH AND HEARING ASSOCIATION
CA163770OtherCALIFORNIA SPEECH HEARING