Provider Demographics
NPI:1629465786
Name:WAKELEY, MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WAKELEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1436
Mailing Address - Country:US
Mailing Address - Phone:304-366-0700
Mailing Address - Fax:304-366-9529
Practice Address - Street 1:1322 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1436
Practice Address - Country:US
Practice Address - Phone:304-366-0700
Practice Address - Fax:304-366-9529
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVCP0069445051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical