Provider Demographics
NPI:1760707418
Name:PROSJE, MICHELLE A (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:PROSJE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 SOUTHPOINT BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-0927
Mailing Address - Country:US
Mailing Address - Phone:904-685-1234
Mailing Address - Fax:866-809-9424
Practice Address - Street 1:4110 SOUTHPOINT BLVD STE 212
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0927
Practice Address - Country:US
Practice Address - Phone:904-685-1234
Practice Address - Fax:866-809-9424
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPPY157103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDH079ZMedicare PIN