Provider Demographics
NPI:1598727109
Name:POORE, MICHELLE A (LIC SW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:POORE
Suffix:
Gender:F
Credentials:LIC SW
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:POORE
Other - Last Name:GRIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LIC SW
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:8675 VALLEY CREEK RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2337
Practice Address - Country:US
Practice Address - Phone:651-501-3000
Practice Address - Fax:651-501-3500
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN077721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN228057400Medicaid
800000870Medicare ID - Type Unspecified
MN228057400Medicaid