Healthcare Provider Details

I. General information

NPI: 1679531040
Provider Name (Legal Business Name): MICHELLE EINSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14551 ADAIR MANOR COURT
CHARLOTTE NC
28277
US

IV. Provider business mailing address

14551 ADAIR MANOR COURT
CHARLOTTE NC
28277
US

V. Phone/Fax

Practice location:
  • Phone: 980-299-1234
  • Fax:
Mailing address:
  • Phone: 980-299-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number4417
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number8936
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4417
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: