Provider Demographics
NPI:1639230618
Name:MASBAUM, MICHELLE ALANE (LCPC, ATR-BC, CDVP)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ALANE
Last Name:MASBAUM
Suffix:
Gender:F
Credentials:LCPC, ATR-BC, CDVP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 HINMAN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4446
Mailing Address - Country:US
Mailing Address - Phone:847-745-3036
Mailing Address - Fax:847-745-3096
Practice Address - Street 1:744 HINMAN AVE APT 2
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-4446
Practice Address - Country:US
Practice Address - Phone:847-745-3036
Practice Address - Fax:847-745-3096
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL05-003221700000X
IL171R00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Not Answered171R00000XOther Service ProvidersInterpreter
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional