Provider Demographics
NPI:1801378450
Name:MICEK, MARAH
Entity type:Individual
Prefix:
First Name:MARAH
Middle Name:
Last Name:MICEK
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 1:4286 GOODWIN LNDG
Mailing Address - Street 2:
Mailing Address - City:KENNEDY
Mailing Address - State:NY
Mailing Address - Zip Code:14747-9624
Mailing Address - Country:US
Mailing Address - Phone:716-338-3915
Mailing Address - Fax:
Practice Address - Street 1:2 EAST AVE N
Practice Address - Street 2:
Practice Address - City:FALCONER
Practice Address - State:NY
Practice Address - Zip Code:14733-1302
Practice Address - Country:US
Practice Address - Phone:716-665-6668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027761235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist