Provider Demographics
NPI:1801378377
Name:KOMETH, MICHELLE MARIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:KOMETH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:HILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:11201 NORTH TATUM BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028
Mailing Address - Country:US
Mailing Address - Phone:480-204-3893
Mailing Address - Fax:
Practice Address - Street 1:11201 N. TATUM BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:PHOENIZ
Practice Address - State:AZ
Practice Address - Zip Code:85028
Practice Address - Country:US
Practice Address - Phone:480-204-3893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-172151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical