Provider Demographics
NPI:1629585252
Name:WALLETT, MICHAEL PATRICK
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:WALLETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14701 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4115
Mailing Address - Country:US
Mailing Address - Phone:216-712-7337
Mailing Address - Fax:216-712-7371
Practice Address - Street 1:14701 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4115
Practice Address - Country:US
Practice Address - Phone:216-712-7337
Practice Address - Fax:216-712-7371
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2418237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist