Basic Information
| Provider Information | |||||||||
| NPI: | 1750049862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACLEAN | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 168 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390590168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505889641 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5901 CROSSLAKE PKWY STE B | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767127010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543006964 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2021 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 117284 | TX | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
ID Information
| ID | Type | State | Issuer | Description | 117284 | 01 | TX | STATE OF TEXAS BOARD OF SPEECH LANGUAGE PATHOLOGIST | OTHER |