Provider Demographics
NPI:1710458161
Name:COHEN, MICKI
Entity Type:Individual
Prefix:
First Name:MICKI
Middle Name:
Last Name:COHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12520 WOLFSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MYERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21773-9302
Mailing Address - Country:US
Mailing Address - Phone:240-236-2250
Mailing Address - Fax:
Practice Address - Street 1:12520 WOLFSVILLE RD
Practice Address - Street 2:
Practice Address - City:MYERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21773-9302
Practice Address - Country:US
Practice Address - Phone:240-236-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD541628100Medicaid