Provider Demographics
NPI:1114613858
Name:SHEGDA, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SHEGDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 OCEAN FRONT WALK
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2403
Mailing Address - Country:US
Mailing Address - Phone:267-303-0965
Mailing Address - Fax:
Practice Address - Street 1:503 OCEAN FRONT WALK
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2403
Practice Address - Country:US
Practice Address - Phone:310-392-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-14
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA146832106H00000X
CAR1497810223101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist