Provider Demographics
NPI:1811446370
Name:HART, MICHELLE J (MSED, BCBA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:HART
Suffix:
Gender:F
Credentials:MSED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8856 131ST RD
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-4403
Mailing Address - Country:US
Mailing Address - Phone:386-209-3545
Mailing Address - Fax:
Practice Address - Street 1:8856 131ST RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060-4403
Practice Address - Country:US
Practice Address - Phone:386-209-3545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X, 251C00000X, 106S00000X, 103K00000X
FL118405500251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118405500Medicaid
FL019534100Medicaid