Healthcare Provider Details

I. General information

NPI: 1225948649
Provider Name (Legal Business Name): MICHAELA MACK CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 W HOWELL RD
MASON MI
48854-9392
US

IV. Provider business mailing address

2673 HENRY RD
JACKSON MI
49201-8234
US

V. Phone/Fax

Practice location:
  • Phone: 517-676-1051
  • Fax:
Mailing address:
  • Phone: 517-358-6061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101005422
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: