Provider Demographics
NPI:1528189438
Name:WOODISON-EVANS, MICHELLE LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:WOODISON-EVANS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:KOLEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17725 WESTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CASNOVIA
Mailing Address - State:MI
Mailing Address - Zip Code:49318-9631
Mailing Address - Country:US
Mailing Address - Phone:616-690-0652
Mailing Address - Fax:616-675-7260
Practice Address - Street 1:15671 ALGOMA AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-8864
Practice Address - Country:US
Practice Address - Phone:616-690-0652
Practice Address - Fax:616-675-7260
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010652971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801065297OtherSTATE LICENSE
MI443587Medicaid
MI1528189438Medicaid
MI443587Medicaid