Provider Demographics
NPI:1225498983
Name:FENTRESS, MICHAEL SHERMAN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHERMAN
Last Name:FENTRESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 HUMBOLDT RD APT 2
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8463
Mailing Address - Country:US
Mailing Address - Phone:352-702-2144
Mailing Address - Fax:
Practice Address - Street 1:2711 HUMBOLDT RD APT 2
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8463
Practice Address - Country:US
Practice Address - Phone:352-702-2144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional