Healthcare Provider Details

I. General information

NPI: 1508433921
Provider Name (Legal Business Name): MICHELLE ROSE HAMPTON LCAS-A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 DOWNEY AVE
MODESTO CA
95354-1208
US

IV. Provider business mailing address

121 DOWNEY AVE
MODESTO CA
95354-1208
US

V. Phone/Fax

Practice location:
  • Phone: 209-341-1824
  • Fax:
Mailing address:
  • Phone: 209-341-1824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAMFT138646
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-27254
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: