Provider Demographics
NPI:1538615307
Name:ANDERSON, MICHELLE LEA (BCABA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:LEA
Other - Last Name:MIMIOGLU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCABA
Mailing Address - Street 1:4351 ANSON LN APT 304
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6355
Mailing Address - Country:US
Mailing Address - Phone:407-865-1509
Mailing Address - Fax:
Practice Address - Street 1:4351 ANSON LN APT 304
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6355
Practice Address - Country:US
Practice Address - Phone:407-865-1509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-11-4091103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst