Provider Demographics
NPI:1457492050
Name:BASALYGA, MICHELLE SUSAN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SUSAN
Last Name:BASALYGA
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 1:104 UPPER KNAPP RD
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2086
Mailing Address - Country:US
Mailing Address - Phone:570-587-9982
Mailing Address - Fax:
Practice Address - Street 1:242 NOBLE RD
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-9406
Practice Address - Country:US
Practice Address - Phone:570-587-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL002711L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11226913OtherCAQH ID
PASL002711LOtherSTATE LICRNSE
PA2601606OtherPROVIDER #
PA758735OtherPROVIDER #