Provider Demographics
NPI:1790808699
Name:KETRICK, MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KETRICK
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 1:2721 N LOGRUN CIR
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-4010
Mailing Address - Country:US
Mailing Address - Phone:281-292-4800
Mailing Address - Fax:281-292-9588
Practice Address - Street 1:19221 INTERSTATE 45 S
Practice Address - Street 2:SUITE 360
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77385-8756
Practice Address - Country:US
Practice Address - Phone:281-292-4800
Practice Address - Fax:281-292-9588
Is Sole Proprietor?:No
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17814235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist