Provider Demographics
NPI:1710575238
Name:WILLIS, MICHELLE SCHURIG
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SCHURIG
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 S 925 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5948
Mailing Address - Country:US
Mailing Address - Phone:801-815-0266
Mailing Address - Fax:
Practice Address - Street 1:195 N 290 W
Practice Address - Street 2:
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-5001
Practice Address - Country:US
Practice Address - Phone:801-785-4749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12017069-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health