Provider Demographics
NPI:1871105056
Name:LIACONE, MICHELLE L
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:LIACONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14557 W INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-9243
Mailing Address - Country:US
Mailing Address - Phone:623-242-6908
Mailing Address - Fax:
Practice Address - Street 1:14557 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-9243
Practice Address - Country:US
Practice Address - Phone:623-242-6908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242006006235Z00000X
AZTSLP12889235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist