Provider Demographics
NPI:1689007262
Name:LASSITER, MICHELLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:LASSITER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2903 TAVISTON DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6911
Mailing Address - Country:US
Mailing Address - Phone:954-305-6757
Mailing Address - Fax:
Practice Address - Street 1:3202 STONE PATH LN SE
Practice Address - Street 2:
Practice Address - City:HAMPTON COVE
Practice Address - State:AL
Practice Address - Zip Code:35763
Practice Address - Country:US
Practice Address - Phone:954-305-6757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-18
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5177235Z00000X
AL3408235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist