Healthcare Provider Details

I. General information

NPI: 1598111684
Provider Name (Legal Business Name): MICHAEL LAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N 34TH ST STE 100
SUPERIOR WI
54880-4476
US

IV. Provider business mailing address

1500 N 34TH ST STE 100
SUPERIOR WI
54880-4476
US

V. Phone/Fax

Practice location:
  • Phone: 715-392-8216
  • Fax: 715-392-6055
Mailing address:
  • Phone: 715-392-8216
  • Fax: 715-392-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: