Provider Demographics
NPI:1164512455
Name:BLACK, MICHELE CATHERINE (MACCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:CATHERINE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6598 TEBBETTS DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-5316
Mailing Address - Country:US
Mailing Address - Phone:407-461-7787
Mailing Address - Fax:
Practice Address - Street 1:2400 S HIGHWAY 27 STE B201
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6816
Practice Address - Country:US
Practice Address - Phone:352-394-0212
Practice Address - Fax:352-241-6361
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
FLSA8723235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890920200Medicaid