Provider Demographics
NPI:1336851211
Name:FENICLE, MARIA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:FENICLE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:FLORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2922 FULLER AVE NE STE 107
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2922 FULLER AVE NE STE 107
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3459
Practice Address - Country:US
Practice Address - Phone:616-570-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist