Provider Demographics
NPI:1306370481
Name:DUNHAM, MICHELLE LEE (CASAC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEE
Last Name:DUNHAM
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:LEE
Other - Last Name:SVRCEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3687 WAITS RD
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-6547
Mailing Address - Country:US
Mailing Address - Phone:607-687-8145
Mailing Address - Fax:607-687-6396
Practice Address - Street 1:1062 STATE ROUTE 38
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-3209
Practice Address - Country:US
Practice Address - Phone:607-687-8145
Practice Address - Fax:607-687-6396
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18532101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249145Medicaid