Provider Demographics
NPI:1467010892
Name:MIRASOLA, MICHELLE COLLETTE (SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:COLLETTE
Last Name:MIRASOLA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:COLLETTE
Other - Last Name:DES JARINDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:724 DENTON ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5447
Practice Address - Country:US
Practice Address - Phone:920-419-5317
Practice Address - Fax:608-782-7300
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
4769235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist