Provider Demographics
NPI:1669856761
Name:MILLWARD, MIKELLE WAITE (MS)
Entity Type:Individual
Prefix:
First Name:MIKELLE
Middle Name:WAITE
Last Name:MILLWARD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLEAVELAND RD APT 102
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-3855
Mailing Address - Country:US
Mailing Address - Phone:208-293-6973
Mailing Address - Fax:
Practice Address - Street 1:111 CLEAVELAND RD APT 102
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523
Practice Address - Country:US
Practice Address - Phone:208-293-6973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24375235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist