Provider Demographics
NPI:1417037102
Name:DR. MICHELLE CHANNING PA
Entity Type:Organization
Organization Name:DR. MICHELLE CHANNING PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANNING
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:954-385-6750
Mailing Address - Street 1:2741 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3641
Mailing Address - Country:US
Mailing Address - Phone:954-385-6750
Mailing Address - Fax:954-385-6757
Practice Address - Street 1:2741 EXECUTIVE PARK DR
Practice Address - Street 2:SUITE 1
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3641
Practice Address - Country:US
Practice Address - Phone:954-385-6750
Practice Address - Fax:954-385-6757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6745103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q0486OtherMEDICARE GROUP PTAN