Provider Demographics
NPI:1255567806
Name:MITCHAM, MICHELLE TONI (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:TONI
Last Name:MITCHAM
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:TONI
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:13325 HARGRAVE RD STE 250
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4545
Mailing Address - Country:US
Mailing Address - Phone:713-352-8090
Mailing Address - Fax:281-754-4253
Practice Address - Street 1:13325 HARGRAVE RD STE 250
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4545
Practice Address - Country:US
Practice Address - Phone:713-352-8090
Practice Address - Fax:281-754-4253
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104660235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist