Provider Demographics
NPI:1184675456
Name:MIKESELL, MICHELE THERESE (MED, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:THERESE
Last Name:MIKESELL
Suffix:
Gender:F
Credentials:MED, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2377 PRINCESS ANNE RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-3535
Mailing Address - Country:US
Mailing Address - Phone:757-427-5987
Mailing Address - Fax:757-563-0887
Practice Address - Street 1:2377 PRINCESS ANNE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-3535
Practice Address - Country:US
Practice Address - Phone:757-427-5987
Practice Address - Fax:757-563-0887
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040016931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA084137OtherSENTARA OPTIMA HMO
VA285335OtherANTHEM PROVIDER NUMBER
VA00V800P52Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER