Provider Demographics
NPI:1801459318
Name:LARGE, MICHELE (MHS-MFT)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:LARGE
Suffix:
Gender:F
Credentials:MHS-MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 MAGNOLIA BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-6395
Mailing Address - Country:US
Mailing Address - Phone:859-492-6177
Mailing Address - Fax:
Practice Address - Street 1:10659 NW SR 20
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321
Practice Address - Country:US
Practice Address - Phone:859-492-6177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor