=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891940870
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE PATRICIA MCHENRY LPC W/ SA SPEC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2008
-----------------------------------------------------
Last Update Date | 01/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 3RD ST N SUITE 205
-----------------------------------------------------
City | LACROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-9303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-782-1400
-----------------------------------------------------
Fax | 608-782-1002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 3RD ST N STE 205
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-3288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-782-1400
-----------------------------------------------------
Fax | 608-782-1002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 5512-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 9720-120
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 5512-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------