Provider Demographics
NPI:1144788811
Name:WAGENKNECHT, MICHELLE LYNNE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNNE
Last Name:WAGENKNECHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-1401
Mailing Address - Country:US
Mailing Address - Phone:630-966-4300
Mailing Address - Fax:847-892-0027
Practice Address - Street 1:1230 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1401
Practice Address - Country:US
Practice Address - Phone:630-966-4300
Practice Address - Fax:847-892-0027
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker