=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336210764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE L MICHENER LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 06/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1370 S COMMERCIAL ST
-----------------------------------------------------
City | NEENAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54956-4636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-268-6940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N433 MAPLERIDGE DR
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54915-8754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-268-6940
-----------------------------------------------------
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 | 740-226
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4816-125
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 4816-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------