Provider Demographics
NPI:1518024033
Name:GHOSTON, MICHELLE R (PHD, LMHC, LPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:GHOSTON
Suffix:
Gender:F
Credentials:PHD, LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 E. BOONE AVE
Mailing Address - Street 2:AD 25
Mailing Address - City:WASHINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:99206-0025
Mailing Address - Country:US
Mailing Address - Phone:509-313-3848
Mailing Address - Fax:509-313-5964
Practice Address - Street 1:502 E. BOONE AVE
Practice Address - Street 2:AD 25
Practice Address - City:WASHINGTON
Practice Address - State:WA
Practice Address - Zip Code:99206-0025
Practice Address - Country:US
Practice Address - Phone:509-313-3848
Practice Address - Fax:509-313-5964
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004092101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945441Medicaid
VA269384OtherANTHEM BLUE SHIELD