Provider Demographics
NPI:1588213854
Name:HOUSEHOLDER, MICHAEL (LCDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HOUSEHOLDER
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 AL LIPSCOMB WAY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75215-2773
Mailing Address - Country:US
Mailing Address - Phone:469-516-4472
Mailing Address - Fax:
Practice Address - Street 1:2010 AL LIPSCOMB WAY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-2773
Practice Address - Country:US
Practice Address - Phone:469-516-4472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12987101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX399885801Medicaid