Provider Demographics
NPI:1114358108
Name:FAST, MICHELLE (PHD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FAST
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 MACKEY BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1360 MACKEY BRANCH DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3225
Practice Address - Country:US
Practice Address - Phone:423-443-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN593740103TS0200X
TN3846103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool