Provider Demographics
NPI:1164633897
Name:OLIVER, MICHELLE L (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:OLIVER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:ELLE
Other - Middle Name:
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1500 HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-7214
Mailing Address - Country:US
Mailing Address - Phone:479-414-9450
Mailing Address - Fax:
Practice Address - Street 1:14 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:AR
Practice Address - Zip Code:72921-3905
Practice Address - Country:US
Practice Address - Phone:479-632-0258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#2512235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR164153721Medicaid