Provider Demographics
NPI:1437340353
Name:BOTTO-BLAKE, MICHELLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:BOTTO-BLAKE
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 1:190 KETTON XING
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-7139
Mailing Address - Country:US
Mailing Address - Phone:770-846-9856
Mailing Address - Fax:
Practice Address - Street 1:190 KETTON XING
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-7139
Practice Address - Country:US
Practice Address - Phone:770-846-9856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005780235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist