Healthcare Provider Details

I. General information

NPI: 1942649066
Provider Name (Legal Business Name): MICHELLE L WYCKOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 W ABRIENDO AVE
PUEBLO CO
81004-1128
US

IV. Provider business mailing address

2109 CHAUTARD DR
PUEBLO CO
81005-2612
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-2746
  • Fax: 719-545-4100
Mailing address:
  • Phone: 719-545-2746
  • Fax: 719-545-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: