Provider Demographics
NPI:1629420104
Name:MICKELSON, SERENA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:MICKELSON
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 1:4506 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1960
Mailing Address - Country:US
Mailing Address - Phone:512-312-8938
Mailing Address - Fax:
Practice Address - Street 1:4506 S 2ND ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1960
Practice Address - Country:US
Practice Address - Phone:512-312-8938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110754235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist