Provider Demographics
NPI:1417499724
Name:EAGLY, MICHELLE D (LPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:EAGLY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:D
Other - Last Name:GILDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6630 MANISTEE ST
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:MI
Mailing Address - Zip Code:49733-9760
Mailing Address - Country:US
Mailing Address - Phone:989-889-0100
Mailing Address - Fax:
Practice Address - Street 1:6630 MANISTEE ST
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:MI
Practice Address - Zip Code:49733-9760
Practice Address - Country:US
Practice Address - Phone:989-889-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015744101YP2500X
MI6401222540101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional