Provider Demographics
NPI:1477681864
Name:KING, MICHELLE RENAE (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENAE
Last Name:KING
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:PO BOX 420
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-0420
Mailing Address - Country:US
Mailing Address - Phone:636-528-7652
Mailing Address - Fax:636-528-2411
Practice Address - Street 1:951 WEST COLLEGE ST
Practice Address - Street 2:LINCOLN COUNTY REORGANIZED
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1112
Practice Address - Country:US
Practice Address - Phone:636-528-7652
Practice Address - Fax:636-528-2411
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016672235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO465102812Medicaid