Provider Demographics
NPI:1689264970
Name:EDWARDS, MICHELLE C (SAC-IT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 N GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-6105
Mailing Address - Country:US
Mailing Address - Phone:262-549-6600
Mailing Address - Fax:
Practice Address - Street 1:2422 N GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-6105
Practice Address - Country:US
Practice Address - Phone:262-549-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19131-130101YA0400X
101YA0400X
WI10131-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI19131-130OtherDSPS