Provider Demographics
NPI:1033889803
Name:WILLOUGHBY, MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 COLUMBUS AVE APT 14A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7067
Mailing Address - Country:US
Mailing Address - Phone:773-992-7728
Mailing Address - Fax:
Practice Address - Street 1:689 COLUMBUS AVE APT 14A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-7067
Practice Address - Country:US
Practice Address - Phone:773-992-7728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0862581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical