Provider Demographics
NPI:1902212897
Name:NAGLY, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:NAGLY
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 1:3920 MYSTIC VALLEY PKWY
Mailing Address - Street 2:APT 218
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3920 MYSTIC VALLEY PKWY
Practice Address - Street 2:APT 218
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-6912
Practice Address - Country:US
Practice Address - Phone:781-572-9156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASP-1173-SA2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant