Provider Demographics
NPI:1336431816
Name:CAST, MICHELLE (MA CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:CAST
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2581 OLD HICKORY DR NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064
Mailing Address - Country:US
Mailing Address - Phone:404-790-0528
Mailing Address - Fax:877-790-3285
Practice Address - Street 1:2581 OLD HICKORY DR NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064
Practice Address - Country:US
Practice Address - Phone:404-790-0528
Practice Address - Fax:877-790-3285
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005412235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003154237AMedicaid
GA003156166AMedicaid