Provider Demographics
NPI:1619995164
Name:LEGAULT, MICHELLE A (LICSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:LEGAULT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANN
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LICSW
Mailing Address - Street 1:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:CULLODEN
Mailing Address - State:WV
Mailing Address - Zip Code:25510-0172
Mailing Address - Country:US
Mailing Address - Phone:304-760-9945
Mailing Address - Fax:681-235-7299
Practice Address - Street 1:3847 TEAYS VALLEY RD STE B
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9820
Practice Address - Country:US
Practice Address - Phone:304-760-9945
Practice Address - Fax:681-235-7299
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP008162261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVLESW24202Medicare PIN
WVLESW24201Medicare PIN