Provider Demographics
NPI:1457861486
Name:LAVALLEY, MICHELLE L (SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:LAVALLEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MS
Other - First Name:MIMI
Other - Middle Name:
Other - Last Name:LAVALLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:409 49TH ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-1920
Mailing Address - Country:US
Mailing Address - Phone:828-696-6695
Mailing Address - Fax:
Practice Address - Street 1:64 AVENUE X
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-5737
Practice Address - Country:US
Practice Address - Phone:718-996-8199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027142235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist