Provider Demographics
NPI:1659618338
Name:HANBY, MICHELLE SUZANNE RIVERA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:SUZANNE RIVERA
Last Name:HANBY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:SUZANNE
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:271 FORT RICHARDSON AVE
Mailing Address - Street 2:
Mailing Address - City:GOODFELLOW AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76908-4901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:271 FORT RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:GOODFELLOW AFB
Practice Address - State:TX
Practice Address - Zip Code:76908-4901
Practice Address - Country:US
Practice Address - Phone:325-654-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36131103TC0700X, 103TB0200X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX343618001Medicaid
TX343618001Medicaid