Provider Demographics
NPI:1447503248
Name:RETZ, ASHLEY MICHELLE (SLP)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MICHELLE
Last Name:RETZ
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 PALM COAST PARKWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137
Mailing Address - Country:US
Mailing Address - Phone:386-597-2820
Mailing Address - Fax:386-597-2820
Practice Address - Street 1:389 PALM COAST PKWY SW
Practice Address - Street 2:SUITE 1
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4771
Practice Address - Country:US
Practice Address - Phone:386-597-2820
Practice Address - Fax:386-597-2820
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 1120235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist