Provider Demographics
NPI:1275630600
Name:HORNER, MICHAEL DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:HORNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BEE ST.
Mailing Address - Street 2:MENTAL HEALTH (116), VAMC
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-5799
Mailing Address - Country:US
Mailing Address - Phone:843-577-5011
Mailing Address - Fax:
Practice Address - Street 1:109 BEE ST.
Practice Address - Street 2:MENTAL HEALTH (116), VAMC
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5799
Practice Address - Country:US
Practice Address - Phone:843-577-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC614103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN