Provider Demographics
NPI:1417274721
Name:WHITLEY, MIRANDA ANNE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:ANNE
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11697 SANDY BOTTOM DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9357
Mailing Address - Country:US
Mailing Address - Phone:517-896-3437
Mailing Address - Fax:
Practice Address - Street 1:11697 SANDY BOTTOM DR
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-9357
Practice Address - Country:US
Practice Address - Phone:517-896-3437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ASHA 12146870235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist