Provider Demographics
NPI:1497813919
Name:MICHELETTI, LAWRENCE S (PHD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:S
Last Name:MICHELETTI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 MARKET ST
Mailing Address - Street 2:STE 609
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550-1530
Mailing Address - Country:US
Mailing Address - Phone:409-772-0848
Mailing Address - Fax:409-772-0885
Practice Address - Street 1:2200 MARKET ST
Practice Address - Street 2:STE 609
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550-1530
Practice Address - Country:US
Practice Address - Phone:409-772-0848
Practice Address - Fax:409-772-0885
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS18959106H00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR69537Medicare UPIN
TX82642WMedicare ID - Type Unspecified