Provider Demographics
NPI:1508424573
Name:NITSCHKE, MICHELLE LYNN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:NITSCHKE
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 1:200 MULLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4194
Mailing Address - Country:US
Mailing Address - Phone:315-782-4483
Mailing Address - Fax:
Practice Address - Street 1:200 MULLIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4194
Practice Address - Country:US
Practice Address - Phone:315-782-4483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003231101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003231OtherINSURANCE