Provider Demographics
NPI:1164187522
Name:ILIEV, MICHELLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ILIEV
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 1:6933 MUNN LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-6131
Mailing Address - Country:US
Mailing Address - Phone:845-263-5725
Mailing Address - Fax:
Practice Address - Street 1:6345 BLACK LAKE BELMORE RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7059
Practice Address - Country:US
Practice Address - Phone:360-709-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL61241074235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist