Provider Demographics
NPI:1396114344
Name:MAITIN, MICHELLE FLORIO
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:FLORIO
Last Name:MAITIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:THERESA
Other - Last Name:FLORIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 SWADDLE LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-0022
Mailing Address - Country:US
Mailing Address - Phone:704-256-1589
Mailing Address - Fax:
Practice Address - Street 1:5114 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-5852
Practice Address - Country:US
Practice Address - Phone:704-364-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11316235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist