Provider Demographics
NPI:1518258110
Name:SANDERSON, MICHELLE MARIE (LPC, SAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:LPC, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 W 9TH ST N
Mailing Address - Street 2:SUITE B
Mailing Address - City:LADYSMITH
Mailing Address - State:WI
Mailing Address - Zip Code:54848-1267
Mailing Address - Country:US
Mailing Address - Phone:715-532-9771
Mailing Address - Fax:715-532-9774
Practice Address - Street 1:804 W 9TH ST N
Practice Address - Street 2:SUITE B
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848-1267
Practice Address - Country:US
Practice Address - Phone:715-532-9771
Practice Address - Fax:715-532-9774
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16214-130101YA0400X
WI5103-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)