Provider Demographics
NPI:1508053984
Name:WANDERS, MICHELLE LEIGH
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEIGH
Last Name:WANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12309 N 127TH LN
Mailing Address - Street 2:
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-2204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15802 N PARKVIEW PL
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7466
Practice Address - Country:US
Practice Address - Phone:623-876-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP5656235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ173181OtherAHCCCS PROVIDER ID