Provider Demographics
NPI:1679021737
Name:HART, MICHELLE B (PHD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:B
Last Name:HART
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6270 CAVAN DR
Mailing Address - Street 2:APT 1
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-5252
Mailing Address - Country:US
Mailing Address - Phone:916-879-1700
Mailing Address - Fax:
Practice Address - Street 1:6270 CAVAN DR
Practice Address - Street 2:APT 1
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-5252
Practice Address - Country:US
Practice Address - Phone:916-879-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17747101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health