Provider Demographics
NPI:1437574944
Name:WIGDZINSKI, MICHELLE RENEE (MA,CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:WIGDZINSKI
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENEE
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:630 SHORE RD. APT 714
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4670
Mailing Address - Country:US
Mailing Address - Phone:440-522-9855
Mailing Address - Fax:
Practice Address - Street 1:65 COURT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:516-595-3720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-20
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026552-01235Z00000X
NY026552235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05001661Medicaid