Provider Demographics
NPI:1679606982
Name:REAL, MICHELLE A (MED)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:REAL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 OPAL CIR
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-6486
Mailing Address - Country:US
Mailing Address - Phone:479-806-3131
Mailing Address - Fax:
Practice Address - Street 1:1214 OPAL CIR
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-6486
Practice Address - Country:US
Practice Address - Phone:479-806-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR12059384235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150236721Medicaid