Provider Demographics
NPI:1366810368
Name:MALLINO, MICHELLE (SLP-CFY)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MALLINO
Suffix:
Gender:F
Credentials:SLP-CFY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14053 MCKINNEY DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-2427
Mailing Address - Country:US
Mailing Address - Phone:586-863-7604
Mailing Address - Fax:
Practice Address - Street 1:42536 HAYES RD
Practice Address - Street 2:STE. 100
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6766
Practice Address - Country:US
Practice Address - Phone:586-286-9644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.003781235Z00000X
MI7101005294235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist