Provider Demographics
NPI:1275046682
Name:HERTTER, MICHELLE S (LCDC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:S
Last Name:HERTTER
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001A W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2206
Mailing Address - Country:US
Mailing Address - Phone:817-338-0311
Mailing Address - Fax:817-332-9075
Practice Address - Street 1:801 ROAD TO SIX FLAGS W
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2616
Practice Address - Country:US
Practice Address - Phone:817-795-3030
Practice Address - Fax:817-795-3099
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12420OtherTEXAS DEPT OF STATE HEALTH SERVICES