Provider Demographics
NPI:1366149627
Name:PRIESTLEY, MICHELLE RENEE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:PRIESTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40043 PROUD MOCKINGBIRD RD
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33540-1512
Mailing Address - Country:US
Mailing Address - Phone:813-785-4807
Mailing Address - Fax:
Practice Address - Street 1:6802 LAKEVIEW CENTER DR STE 500
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-1169
Practice Address - Country:US
Practice Address - Phone:813-954-9622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities