Healthcare Provider Details

I. General information

NPI: 1982948576
Provider Name (Legal Business Name): MICHELLE TULLETT CHARLEY M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE T CHARLEY M.A., CCC-SLP

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 W TOUHY AVE
PARK RIDGE IL
60068-3232
US

IV. Provider business mailing address

329 S LINCOLN AVE
PARK RIDGE IL
60068-3813
US

V. Phone/Fax

Practice location:
  • Phone: 224-585-6003
  • Fax:
Mailing address:
  • Phone: 847-720-4954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146-007202
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: