Provider Demographics
NPI:1184192866
Name:ANDERSON, MICHELLE (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:HEREFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3733 UNIVERSITY BLVD W STE 212
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2155
Mailing Address - Country:US
Mailing Address - Phone:904-990-7117
Mailing Address - Fax:
Practice Address - Street 1:3733 UNIVERSITY BLVD W STE 212
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2155
Practice Address - Country:US
Practice Address - Phone:904-990-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-11
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health