Provider Demographics
NPI:1245514660
Name:WILLIAMSON, MICHELLE LORRAINE (MA, CCC-SLP/NYS LIC)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LORRAINE
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP/NYS LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 N MAIN STREET RD
Mailing Address - Street 2:
Mailing Address - City:HOLLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14470-9381
Mailing Address - Country:US
Mailing Address - Phone:585-638-6318
Mailing Address - Fax:
Practice Address - Street 1:3800 N MAIN STREET RD
Practice Address - Street 2:
Practice Address - City:HOLLEY
Practice Address - State:NY
Practice Address - Zip Code:14470-9381
Practice Address - Country:US
Practice Address - Phone:585-638-6318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007199-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01085690OtherASHA CERTIFICATION
NY007199-1OtherNYS SPEECH-LANGUAGE PATHOLOGIST LICENSE