Healthcare Provider Details

I. General information

NPI: 1356674949
Provider Name (Legal Business Name): MICHELLE BRANCH MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE BURKHALTER MS

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date: 09/22/2020
Reactivation Date: 09/30/2020

III. Provider practice location address

4530 E MUIRWOOD DR STE 103
PHOENIX AZ
85048
US

IV. Provider business mailing address

27777 INKSTER RD
FARMINGTON HILLS MI
48334-5326
US

V. Phone/Fax

Practice location:
  • Phone: 480-610-6981
  • Fax: 480-898-7419
Mailing address:
  • Phone: 248-436-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: