Provider Demographics
NPI:1437477866
Name:BENNETT, MICHELE L (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:L
Last Name:BENNETT
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 1:1963 WILD STAR WAY
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-7505
Mailing Address - Country:US
Mailing Address - Phone:303-945-6966
Mailing Address - Fax:
Practice Address - Street 1:1963 WILD STAR WAY
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-7505
Practice Address - Country:US
Practice Address - Phone:303-945-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO01074841235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist