Provider Demographics
NPI:1568993046
Name:MICHELLE M GIENAU, LCSW, LLC
Entity Type:Organization
Organization Name:MICHELLE M GIENAU, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIENAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-334-4125
Mailing Address - Street 1:PO BOX 122
Mailing Address - Street 2:
Mailing Address - City:YANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06389-0122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 HALLS RD
Practice Address - Street 2:# 234
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1457
Practice Address - Country:US
Practice Address - Phone:860-434-5398
Practice Address - Fax:860-434-5473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-25
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT96771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty