Healthcare Provider Details

I. General information

NPI: 1629420104
Provider Name (Legal Business Name): SERENA MICKELSON M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 S OAKES ST APT 3
TACOMA WA
98405-2792
US

IV. Provider business mailing address

613 S OAKES ST APT 3
TACOMA WA
98405-2792
US

V. Phone/Fax

Practice location:
  • Phone: 512-312-8938
  • Fax:
Mailing address:
  • Phone: 512-312-8938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number110754
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: