Provider Demographics
NPI:1891258992
Name:SRIVASTAVA, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SRIVASTAVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:KIZAUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 FORREST PL
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4801
Mailing Address - Country:US
Mailing Address - Phone:314-761-1942
Mailing Address - Fax:
Practice Address - Street 1:11785 NORTHFALL LN STE 501-502
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-7971
Practice Address - Country:US
Practice Address - Phone:770-569-2274
Practice Address - Fax:770-569-7432
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010062235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist