Provider Demographics
NPI:1295900371
Name:HERBST, MICHELLE A (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:A
Last Name:HERBST
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:A
Other - Last Name:MACKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:47 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-2114
Mailing Address - Country:US
Mailing Address - Phone:631-924-6255
Mailing Address - Fax:
Practice Address - Street 1:47 NOTTINGHAM DR
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2114
Practice Address - Country:US
Practice Address - Phone:631-924-6255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011976-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist