Provider Demographics
NPI:1588862957
Name:HARDEMAN-GUPTILL, MICHELLE (LMFT CCHT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HARDEMAN-GUPTILL
Suffix:
Gender:F
Credentials:LMFT CCHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 JUANITA CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-9046
Mailing Address - Country:US
Mailing Address - Phone:707-972-6639
Mailing Address - Fax:
Practice Address - Street 1:406 CHINN ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4339
Practice Address - Country:US
Practice Address - Phone:707-387-0167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF71897101YM0800X, 106H00000X
101YM0800X
CALMFT99852106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health