Provider Demographics
NPI:1699216085
Name:GAST, MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GAST
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-1630
Mailing Address - Country:US
Mailing Address - Phone:443-262-5754
Mailing Address - Fax:
Practice Address - Street 1:645 BALTIMORE ANNAPOLIS BLVD
Practice Address - Street 2:SUITE # 111
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-3931
Practice Address - Country:US
Practice Address - Phone:410-544-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08177235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist