Provider Demographics
NPI:1659986602
Name:TARANTINO, MICHAEL NICHOLAS (SLP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:NICHOLAS
Last Name:TARANTINO
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2399 FERRAND ST STE H
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3208
Mailing Address - Country:US
Mailing Address - Phone:318-460-5150
Mailing Address - Fax:
Practice Address - Street 1:2399 FERRAND ST STE H
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3208
Practice Address - Country:US
Practice Address - Phone:318-460-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6022235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist