Provider Demographics
NPI:1124192760
Name:SANBORN, MICHELLE DAWN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DAWN
Last Name:SANBORN
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 1:450 VAUGHN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-1944
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16349 BEAVER PIKE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-8511
Practice Address - Country:US
Practice Address - Phone:740-286-2790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5141235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5141OtherOHIO LICENSE