Provider Demographics
NPI:1164277489
Name:KNOWLES, MIKAELA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:KNOWLES
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 1:2611 PRINGLE RD SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1533
Mailing Address - Country:US
Mailing Address - Phone:503-385-4857
Mailing Address - Fax:
Practice Address - Street 1:2611 PRINGLE RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1533
Practice Address - Country:US
Practice Address - Phone:503-385-4857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR013574235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist