Provider Demographics
NPI:1790082501
Name:AYALA-FELICIANO, MICHELLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:AYALA-FELICIANO
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 1:4400 W SPRUCE ST APT 105
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-4147
Mailing Address - Country:US
Mailing Address - Phone:787-249-4600
Mailing Address - Fax:
Practice Address - Street 1:4400 W SPRUCE ST APT 105
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-4147
Practice Address - Country:US
Practice Address - Phone:787-249-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 9045103TR0400X, 103TC0700X, 103TH0004X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1790082501Medicaid
FL1790082501Medicaid