Provider Demographics
NPI:1417384587
Name:WHEATON, MICHAEL EDWARD (LMFT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:WHEATON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 W MAIN ST STE 214
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2439
Mailing Address - Country:US
Mailing Address - Phone:605-988-8122
Mailing Address - Fax:605-988-8141
Practice Address - Street 1:2525 W MAIN ST STE 214
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2439
Practice Address - Country:US
Practice Address - Phone:605-988-8122
Practice Address - Fax:605-988-8141
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLMFT1212106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6573480Medicaid