Healthcare Provider Details

I. General information

NPI: 1083549786
Provider Name (Legal Business Name): MICAH WOLLENBERG LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 STUDIO DR
LA MARQUE TX
77568-6116
US

IV. Provider business mailing address

806 STUDIO DR
LA MARQUE TX
77568-6116
US

V. Phone/Fax

Practice location:
  • Phone: 720-206-9201
  • Fax:
Mailing address:
  • Phone: 720-206-9201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number96640
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: