Provider Demographics
NPI:1790505964
Name:GWALTNEY, MICHELLE L (LICENSED PASTORAL CO)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:GWALTNEY
Suffix:
Gender:F
Credentials:LICENSED PASTORAL CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 E MARION AVE UNIT 117A
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-3715
Mailing Address - Country:US
Mailing Address - Phone:404-938-1469
Mailing Address - Fax:
Practice Address - Street 1:265 E MARION AVE UNIT 117A
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3715
Practice Address - Country:US
Practice Address - Phone:404-938-1469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22374101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral