=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114223534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE RENE WALBLAY M.ED.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2011
-----------------------------------------------------
Last Update Date | 02/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8603 E EASTRIDGE RD SUITE A
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86314-8562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-777-3260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8603 E EASTRIDGE RD SUITE A
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86314-8562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-777-3260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 11620
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------