Provider Demographics
NPI:1114967783
Name:TRUDELL, MICHELLE (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TRUDELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4771 2 MILE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-2775
Mailing Address - Country:US
Mailing Address - Phone:989-778-2323
Mailing Address - Fax:989-778-2322
Practice Address - Street 1:4771 2 MILE RD
Practice Address - Street 2:SUITE A
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2775
Practice Address - Country:US
Practice Address - Phone:989-778-2323
Practice Address - Fax:989-778-2322
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801087718104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7509105760OtherBCBS
MI20636OtherBCBS SA
MI0G96288Medicare UPIN
MI20636OtherBCBS SA