Provider Demographics
NPI:1194372888
Name:WEDDLE, MICHELLE LYNN
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:WEDDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:GROGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:719 12TH ST
Mailing Address - Street 2:
Mailing Address - City:KAMIAH
Mailing Address - State:ID
Mailing Address - Zip Code:83536-5325
Mailing Address - Country:US
Mailing Address - Phone:208-790-3014
Mailing Address - Fax:
Practice Address - Street 1:719 12TH ST
Practice Address - Street 2:
Practice Address - City:KAMIAH
Practice Address - State:ID
Practice Address - Zip Code:83536-5325
Practice Address - Country:US
Practice Address - Phone:208-790-3014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst