Provider Demographics
NPI:1114642089
Name:MIKVIMAN, MICHELLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MIKVIMAN
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 1:176 GLENIFFER HILL RD
Mailing Address - Street 2:
Mailing Address - City:RICHBORO
Mailing Address - State:PA
Mailing Address - Zip Code:18954-1367
Mailing Address - Country:US
Mailing Address - Phone:267-528-8600
Mailing Address - Fax:
Practice Address - Street 1:290 ANDREWS RD STE 106
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-3480
Practice Address - Country:US
Practice Address - Phone:267-528-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL016650235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist