Provider Demographics
NPI:1013791961
Name:MEDLER, MICHELLE D (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:MEDLER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9778 S CARLSON RD
Mailing Address - Street 2:
Mailing Address - City:FENWICK
Mailing Address - State:MI
Mailing Address - Zip Code:48834-9506
Mailing Address - Country:US
Mailing Address - Phone:616-802-0290
Mailing Address - Fax:
Practice Address - Street 1:9778 S CARLSON RD
Practice Address - Street 2:
Practice Address - City:FENWICK
Practice Address - State:MI
Practice Address - Zip Code:48834-9506
Practice Address - Country:US
Practice Address - Phone:616-802-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2203000916235Z00000X
MI7101000260235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist