Provider Demographics
NPI:1770921561
Name:FRICKS, MICHELLE DIANE (MS SLP-CCC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANE
Last Name:FRICKS
Suffix:
Gender:F
Credentials:MS SLP-CCC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:DIANE
Other - Last Name:RUF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1177 N WARSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-1810
Mailing Address - Country:US
Mailing Address - Phone:314-569-2211
Mailing Address - Fax:314-569-0778
Practice Address - Street 1:1177 N WARSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-1810
Practice Address - Country:US
Practice Address - Phone:314-569-2211
Practice Address - Fax:314-569-0778
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015000523235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist