Provider Demographics
NPI:1447873542
Name:GARRIS, MICHELLE KAY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KAY
Last Name:GARRIS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 AARON DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3065
Mailing Address - Country:US
Mailing Address - Phone:618-234-2690
Mailing Address - Fax:
Practice Address - Street 1:4732 PATRIOTS DR
Practice Address - Street 2:
Practice Address - City:SCOTT AIR FORCE BASE
Practice Address - State:IL
Practice Address - Zip Code:62225-1197
Practice Address - Country:US
Practice Address - Phone:618-746-4738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146006677235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist