Provider Demographics
NPI:1568223196
Name:ALTEKRUSE, MICHAEL CLIFFORD (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CLIFFORD
Last Name:ALTEKRUSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 APPLE BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-4420
Mailing Address - Country:US
Mailing Address - Phone:920-428-6614
Mailing Address - Fax:
Practice Address - Street 1:1180 APPLE BLOSSOM DR
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4420
Practice Address - Country:US
Practice Address - Phone:920-428-6614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2118-057103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling