Provider Demographics
NPI:1376849414
Name:HULSTROM, MICHELLE ANNE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANNE
Last Name:HULSTROM
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 CUMBRIA WAY
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-9668
Mailing Address - Country:US
Mailing Address - Phone:209-609-5179
Mailing Address - Fax:209-263-7006
Practice Address - Street 1:2826 CUMBRIA WAY
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-9668
Practice Address - Country:US
Practice Address - Phone:209-609-5179
Practice Address - Fax:209-263-7006
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12799235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist