Provider Demographics
NPI:1346323193
Name:LACROSSE, MICHAEL BERNARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BERNARD
Last Name:LACROSSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2702 ROLLING HILLS DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-3042
Mailing Address - Country:US
Mailing Address - Phone:402-379-1361
Mailing Address - Fax:402-844-3828
Practice Address - Street 1:1309 N 9TH ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-0854
Practice Address - Country:US
Practice Address - Phone:402-371-5306
Practice Address - Fax:402-844-3828
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE71103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE096413Medicare ID - Type Unspecified