Provider Demographics
NPI:1811669930
Name:COLLICA, MICHELLE LAUREN (MA CCC-SLP, TSSLD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LAUREN
Last Name:COLLICA
Suffix:
Gender:F
Credentials:MA CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1428 5TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4147
Practice Address - Country:US
Practice Address - Phone:516-306-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist