Provider Demographics
NPI:1659789469
Name:BURT, MICHELLE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:BURT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1 SHIELDS AVE
Mailing Address - Street 2:219 NORTH HALL, STUDENT HEALTH & COUNSELING SERVICES
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5270
Mailing Address - Country:US
Mailing Address - Phone:530-752-0871
Mailing Address - Fax:530-752-9923
Practice Address - Street 1:1 SHIELDS AVE
Practice Address - Street 2:219 NORTH HALL, STUDENT HEALTH & COUNSELING SERVICES
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5270
Practice Address - Country:US
Practice Address - Phone:530-752-0871
Practice Address - Fax:530-752-9923
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 26468103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist