Provider Demographics
NPI:1154694875
Name:REXACH, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:REXACH
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 1:2901 W SAINT ISABEL ST STE A1
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6350
Mailing Address - Country:US
Mailing Address - Phone:888-666-3089
Mailing Address - Fax:888-666-9870
Practice Address - Street 1:2901 W SAINT ISABEL ST STE A1
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6350
Practice Address - Country:US
Practice Address - Phone:888-666-3089
Practice Address - Fax:888-666-9870
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLSS905103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst