Healthcare Provider Details

I. General information

NPI: 1609748789
Provider Name (Legal Business Name): BERNADETTE MIQUE CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2025
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 SUDBROOK LN STE A
BALTIMORE MD
21208-4184
US

IV. Provider business mailing address

707 S ROBINSON ST
BALTIMORE MD
21224-3940
US

V. Phone/Fax

Practice location:
  • Phone: 443-918-5575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number11664
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: