Provider Demographics
NPI:1366639015
Name:HARGRAVE, MICHELLE RENEE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENEE
Last Name:HARGRAVE
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 1:4505 BALI CT NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2801
Mailing Address - Country:US
Mailing Address - Phone:505-292-7104
Mailing Address - Fax:505-296-2183
Practice Address - Street 1:4505 BALI CT NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2801
Practice Address - Country:US
Practice Address - Phone:505-292-7104
Practice Address - Fax:505-296-2183
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4367235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04481054Medicaid