Provider Demographics
NPI:1518149483
Name:MUTH, MICHELLE L (SW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:MUTH
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:WEHRWEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SW
Mailing Address - Street 1:64 ECLIPSE CENTER
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511
Mailing Address - Country:US
Mailing Address - Phone:608-363-6200
Mailing Address - Fax:
Practice Address - Street 1:64 ECLIPSE CTR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3550
Practice Address - Country:US
Practice Address - Phone:608-363-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6169-120104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker