Provider Demographics
NPI:1881901387
Name:WARDELL, MICHELLE TRACY (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:TRACY
Last Name:WARDELL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:TRACY
Other - Last Name:LEDOUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:69 W WATERLOO ST
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-1139
Mailing Address - Country:US
Mailing Address - Phone:614-833-2608
Mailing Address - Fax:
Practice Address - Street 1:69 W WATERLOO ST
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-1139
Practice Address - Country:US
Practice Address - Phone:614-833-2608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP5803235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist