Healthcare Provider Details

I. General information

NPI: 1184029001
Provider Name (Legal Business Name): MICHELLE WAHULA, LMSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 N MAIN ST SUITE F
ROMEO MI
48065-4616
US

IV. Provider business mailing address

228 N MAIN ST SUITE F
ROMEO MI
48065-4616
US

V. Phone/Fax

Practice location:
  • Phone: 586-894-8410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number6801094043
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6801094043
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number6801094043
License Number StateMI

VIII. Authorized Official

Name: MRS. MICHELLE WAHULA
Title or Position: LICENSED THERAPIST
Credential: LMSW
Phone: 586-894-8410