Provider Demographics
NPI:1891542338
Name:HALLIDAY, MICHELLE LEE
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEE
Last Name:HALLIDAY
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 1:16972 OVAL RUM DR
Mailing Address - Street 2:
Mailing Address - City:WIMAUMA
Mailing Address - State:FL
Mailing Address - Zip Code:33598-2434
Mailing Address - Country:US
Mailing Address - Phone:813-767-4447
Mailing Address - Fax:
Practice Address - Street 1:815 S PARSONS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6063
Practice Address - Country:US
Practice Address - Phone:941-263-1451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician