Provider Demographics
NPI:1033764469
Name:DAMM, MICHELLE J (LPC-IT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:DAMM
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:J
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC-IT
Mailing Address - Street 1:667 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1738
Mailing Address - Country:US
Mailing Address - Phone:920-366-2597
Mailing Address - Fax:
Practice Address - Street 1:418 E WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3040
Practice Address - Country:US
Practice Address - Phone:414-429-6403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4423-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional