Provider Demographics
NPI:1629520192
Name:SAN ANTONIO, MICHELE JEAN (MS CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:MICHELE
Middle Name:JEAN
Last Name:SAN ANTONIO
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4334 MATILIJA AVE
Mailing Address - Street 2:APT. 220
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3660
Mailing Address - Country:US
Mailing Address - Phone:401-269-9410
Mailing Address - Fax:
Practice Address - Street 1:5301 LAUREL CANYON BLVD
Practice Address - Street 2:SUITE 245
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-2736
Practice Address - Country:US
Practice Address - Phone:818-435-2960
Practice Address - Fax:818-439-2903
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CASP 13836235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist