Provider Demographics
NPI:1457442683
Name:BENGTSON, MICHELLE
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:BENGTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E BOB JONES RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-9216
Mailing Address - Country:US
Mailing Address - Phone:817-491-2481
Mailing Address - Fax:
Practice Address - Street 1:700 E SOUTHLAKE BLVD STE 190
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6351
Practice Address - Country:US
Practice Address - Phone:817-251-0911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30853103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX30853OtherLICENSE-PSYCHOLOGY
TX30853OtherLICENSE-PSYCHOLOGY