Healthcare Provider Details

I. General information

NPI: 1245617679
Provider Name (Legal Business Name): MICHELLE LEE VAN THIEL I LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE LEE MCFARLAN APSW

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N9487 COUNTY RD N
APPLETON WI
54915-9316
US

IV. Provider business mailing address

N9487 COUNTRY ROAD N
APPLETON WI
54915
US

V. Phone/Fax

Practice location:
  • Phone: 920-850-7902
  • Fax:
Mailing address:
  • Phone: 920-850-7902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-7257
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: