Healthcare Provider Details

I. General information

NPI: 1922335017
Provider Name (Legal Business Name): MICHELLE M. BISHOP, PHD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2009
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2653 SW 87TH DR STE A
GAINESVILLE FL
32608-9313
US

IV. Provider business mailing address

2653 SW 87TH DR STE A
GAINESVILLE FL
32608-9313
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-0020
  • Fax: 352-331-0022
Mailing address:
  • Phone: 352-331-0020
  • Fax: 352-331-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY6140
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPY6140
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY6140
License Number StateFL

VIII. Authorized Official

Name: DONNA ROSE
Title or Position: OFFICE MANAGER
Credential:
Phone: 352-331-0020