Healthcare Provider Details

I. General information

NPI: 1841702743
Provider Name (Legal Business Name): MICHELLE JAMES PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE TABIGUE

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E WILLETTA ST
PHOENIX AZ
85006-2727
US

IV. Provider business mailing address

4140 N CENTRAL AVE APT 3085
PHOENIX AZ
85012-1861
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-6900
  • Fax:
Mailing address:
  • Phone: 602-748-0912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4908
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number4908
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: