Healthcare Provider Details

I. General information

NPI: 1083737811
Provider Name (Legal Business Name): MICHELLE RENEE CIUCCI CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 WESTFALIAN TRL
AUSTIN TX
78732-1967
US

IV. Provider business mailing address

2100 WESTFALIAN TRL
AUSTIN TX
78732-1967
US

V. Phone/Fax

Practice location:
  • Phone: 512-587-5671
  • Fax: 512-535-6786
Mailing address:
  • Phone: 512-587-5671
  • Fax: 512-535-6786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number102240
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: