Provider Demographics
NPI:1629169800
Name:WALLER, MICHELLE (MACCC-A)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:MACCC-A
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:COPPOLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:251 LYMAN RD
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-6249
Mailing Address - Country:US
Mailing Address - Phone:631-286-9366
Mailing Address - Fax:
Practice Address - Street 1:375 EAST MAIN STREET STE. 17
Practice Address - Street 2:
Practice Address - City:BAYSHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-665-6922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002098-1231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist