Provider Demographics
NPI:1497999361
Name:AMY MICKLICH SPEECH LANGUAGE PATHOLOGY SERVICES
Entity Type:Organization
Organization Name:AMY MICKLICH SPEECH LANGUAGE PATHOLOGY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MICKLICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-578-8348
Mailing Address - Street 1:293 SPRING ST.
Mailing Address - Street 2:P.O. BOX 69
Mailing Address - City:ROCKVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02873-0069
Mailing Address - Country:US
Mailing Address - Phone:401-578-8348
Mailing Address - Fax:401-539-2319
Practice Address - Street 1:293 SPRING ST.
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:RI
Practice Address - Zip Code:02873-0069
Practice Address - Country:US
Practice Address - Phone:401-578-8348
Practice Address - Fax:401-539-2319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISP00578235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty