Provider Demographics
NPI:1407533243
Name:MATHEW, MICHELLE SUSAN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SUSAN
Last Name:MATHEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52643 BELLE POINTE CT
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-2916
Mailing Address - Country:US
Mailing Address - Phone:248-403-4920
Mailing Address - Fax:
Practice Address - Street 1:43902 WOODWARD AVE STE 230
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5022
Practice Address - Country:US
Practice Address - Phone:248-481-8428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023124101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor