Provider Demographics
NPI:1841720273
Name:ERTL, MICHELLE (PSYD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ERTL
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 1:2636 S IMPERIAL ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3615
Mailing Address - Country:US
Mailing Address - Phone:719-221-9971
Mailing Address - Fax:
Practice Address - Street 1:4525 S 2300 E STE 201
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4639
Practice Address - Country:US
Practice Address - Phone:801-896-7624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10244648-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist