Basic Information
| Provider Information | |||||||||
| NPI: | 1982273033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARACLE | ||||||||
| FirstName: | MERISSA | ||||||||
| MiddleName: | RENE | ||||||||
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| Credential: | M.A., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1525 RIDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486426425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898356333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1525 RIDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486426425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898356333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2021 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7101007531 | MI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.