Provider Demographics
NPI:1770984007
Name:FIREWORKER, MICHELLE (SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FIREWORKER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 CLIFFSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3049
Mailing Address - Country:US
Mailing Address - Phone:516-633-3688
Mailing Address - Fax:
Practice Address - Street 1:923 CLIFFSIDE AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3049
Practice Address - Country:US
Practice Address - Phone:516-633-3688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022340-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist