Healthcare Provider Details

I. General information

NPI: 1306962279
Provider Name (Legal Business Name): MICHELLE YETMAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 11/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 CLAIBORNE AVE LSUHSC-ALLIED HEALTH CLINICS
SHREVEPORT LA
71103-4204
US

IV. Provider business mailing address

1501 KINGS HWY LSUHSC-ALLIED HEALTH CLINICS
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-813-2970
  • Fax: 318-813-2981
Mailing address:
  • Phone: 318-813-2970
  • Fax: 318-813-2981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number908
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: