Provider Demographics
NPI:1144744723
Name:MICHELLE OLIPHANT, LLC
Entity Type:Organization
Organization Name:MICHELLE OLIPHANT, LLC
Other - Org Name:MICHELLE OLIPHANT, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIPHANT
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:316-500-3711
Mailing Address - Street 1:4601 E DOUGLAS AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1032
Mailing Address - Country:US
Mailing Address - Phone:1316-500-3711
Mailing Address - Fax:
Practice Address - Street 1:4601 E DOUGLAS AVE STE 120
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1032
Practice Address - Country:US
Practice Address - Phone:316-500-3711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10366261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201157740AMedicaid