Provider Demographics
NPI:1629571872
Name:WAREHAM, MICHELLE (LCAS-A LPC-A)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WAREHAM
Suffix:
Gender:F
Credentials:LCAS-A LPC-A
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WAREHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MICHELLE WAREHAM
Mailing Address - Street 1:918 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-4642
Mailing Address - Country:US
Mailing Address - Phone:919-632-3415
Mailing Address - Fax:
Practice Address - Street 1:1001 NAVAHO DR STE GL103
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7368
Practice Address - Country:US
Practice Address - Phone:919-431-9874
Practice Address - Fax:919-431-9875
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13703101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty