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NPI Code Detail

MEDICARE: MRS. LISA ILENE MICKLE SLP,CCC

MEDICARE: MRS. LISA ILENE MICKLE SLP,CCC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1235Z00000XSpeech-Language Pathologist005887-1NY

General Provider Information

NPI Number : 1003192766
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. LISA ILENE MICKLE SLP,CCC
Provider Business Mailing Address
First Line : 525 HALF HOLLOW RD
Second Line :
City : DIX HILLS
State : NY
Zip : 11746-5828
Country : US
Telephone Number : 631-592-3300
Fax Number :
Provider Business Practice Location Address
First Line : 525 HALF HOLLOW RD
Second Line :
City : DIX HILLS
State : NY
Zip : 11746-5828
Country : US
Telephone Number : 631-592-3000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/26/2011
Last Update Date : 10/26/2011

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