Provider Demographics
NPI:1255587028
Name:GADDIS, MICHELE (SLP)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:GADDIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:ROGERS-GADDIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:25150 HANCOCK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5987
Practice Address - Country:US
Practice Address - Phone:951-698-7720
Practice Address - Fax:951-698-7451
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 10228235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU334ZMedicare PIN