Provider Demographics
NPI:1770021149
Name:MICELI, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MICELI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E SHERIDAN ST
Mailing Address - Street 2:APT 6
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2956
Mailing Address - Country:US
Mailing Address - Phone:248-762-8418
Mailing Address - Fax:
Practice Address - Street 1:2206 MITCHELL PARK DR
Practice Address - Street 2:SUITE 14
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8674
Practice Address - Country:US
Practice Address - Phone:231-348-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005418235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist