Provider Demographics
NPI:1417611872
Name:HARDY, MICHELLE (LPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HARDY
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2569
Mailing Address - Country:US
Mailing Address - Phone:909-856-5724
Mailing Address - Fax:
Practice Address - Street 1:1889 W REDLANDS BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-3119
Practice Address - Country:US
Practice Address - Phone:909-501-5167
Practice Address - Fax:909-801-8133
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30417167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician