Provider Demographics
NPI:1265831796
Name:SPANGENBURG, MICHAELA KYM (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAELA
Middle Name:KYM
Last Name:SPANGENBURG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7725 BROADWAY STE A
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-4787
Mailing Address - Country:US
Mailing Address - Phone:707-736-1000
Mailing Address - Fax:
Practice Address - Street 1:7725 BROADWAY STE A
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-4787
Practice Address - Country:US
Practice Address - Phone:707-736-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043453A103TC0700X, 103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health