Provider Demographics
NPI:1649406232
Name:REIDY, MICAH (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:REIDY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:MICAH
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:1250 NE LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370
Mailing Address - Country:US
Mailing Address - Phone:800-967-4667
Mailing Address - Fax:866-273-4090
Practice Address - Street 1:1250 NE LINCOLN RD
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370
Practice Address - Country:US
Practice Address - Phone:800-967-4667
Practice Address - Fax:866-273-4090
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1050112355S0801X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant