Provider Demographics
NPI:1538470190
Name:MERSDORF, MICHELLE ELAINE (MS)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ELAINE
Last Name:MERSDORF
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3236 OLD 63 N
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-3682
Mailing Address - Country:US
Mailing Address - Phone:601-766-0054
Mailing Address - Fax:
Practice Address - Street 1:3236 OLD 63 N
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-3682
Practice Address - Country:US
Practice Address - Phone:601-766-0054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1776101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor