Provider Demographics
NPI:1720584089
Name:LAGE, MICHELLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LAGE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1901
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-656-7115
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1901
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-656-7115
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5971235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41-0695596Medicaid