Provider Demographics
NPI:1417495185
Name:HARTER, MICHELLE (CADTP#5004)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HARTER
Suffix:
Gender:F
Credentials:CADTP#5004
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 S HALE AVE SPC 45
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-2177
Mailing Address - Country:US
Mailing Address - Phone:760-666-2639
Mailing Address - Fax:
Practice Address - Street 1:1560 CAPALINA RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-1288
Practice Address - Country:US
Practice Address - Phone:760-744-2104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5004101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)