Provider Demographics
NPI:1235579053
Name:WEGNER, MICHELLE R (PC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:WEGNER
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-5524
Mailing Address - Country:US
Mailing Address - Phone:715-842-0944
Mailing Address - Fax:715-845-6477
Practice Address - Street 1:1509 N 4TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-2142
Practice Address - Country:US
Practice Address - Phone:800-236-3792
Practice Address - Fax:715-845-6477
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1497-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1235579053Medicaid