Provider Demographics
NPI:1679808935
Name:HAESE, MICHELLE R (CAPSW, CSAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:HAESE
Suffix:
Gender:F
Credentials:CAPSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 31
Mailing Address - Street 2:W9071 FOREST DR
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-0031
Mailing Address - Country:US
Mailing Address - Phone:920-526-3244
Mailing Address - Fax:
Practice Address - Street 1:W9071 FOREST DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-0031
Practice Address - Country:US
Practice Address - Phone:920-526-3244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15615-130101YA0400X
WI128008-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker