Provider Demographics
NPI:1003486523
Name:MICHENER CHILD AND ADOLESCENT COUNSELING, LLC
Entity Type:Organization
Organization Name:MICHENER CHILD AND ADOLESCENT COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHENER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:920-268-6940
Mailing Address - Street 1:N433 MAPLERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-8754
Mailing Address - Country:US
Mailing Address - Phone:920-268-6940
Mailing Address - Fax:
Practice Address - Street 1:1370 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4636
Practice Address - Country:US
Practice Address - Phone:920-268-6940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1245830926Medicaid
WI1336210764Medicaid
WI1780225292Medicaid