Provider Demographics
NPI:1659137149
Name:DEWOLFE, MICHELLE ANTONINA (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANTONINA
Last Name:DEWOLFE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 W SOUTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3961 HOLIDAY DR
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-4693
Practice Address - Country:US
Practice Address - Phone:817-881-3884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110683104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker