=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568779981
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AARON MICHELSON PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2010
-----------------------------------------------------
Last Update Date | 06/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 E MAIN ST
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61832-5100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-554-4110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 CROCKETT ST APT 614
-----------------------------------------------------
City | CATLIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61817-9681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-867-4926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 10376
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------