Healthcare Provider Details

I. General information

NPI: 1164512455
Provider Name (Legal Business Name): MICHELE CATHERINE BLACK M.A.CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 02/16/2025
Certification Date: 02/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1757 INDIANA AVE
WINTER PARK FL
32789-5446
US

IV. Provider business mailing address

1757 INDIANA AVE
WINTER PARK FL
32789-5446
US

V. Phone/Fax

Practice location:
  • Phone: 407-461-7787
  • Fax: 407-988-1514
Mailing address:
  • Phone: 407-461-7787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA8723
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: