Healthcare Provider Details

I. General information

NPI: 1376849414
Provider Name (Legal Business Name): MICHELLE ANNE HULSTROM CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2826 CUMBRIA WAY
LODI CA
95242-9668
US

IV. Provider business mailing address

2826 CUMBRIA WAY
LODI CA
95242-9668
US

V. Phone/Fax

Practice location:
  • Phone: 209-609-5179
  • Fax: 209-263-7006
Mailing address:
  • Phone: 209-609-5179
  • Fax: 209-263-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12799
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: