Provider Demographics
NPI:1720376916
Name:NACKE, MICHELE (LPC)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:NACKE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18820 PIKE 9230
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:MO
Mailing Address - Zip Code:63334-3853
Mailing Address - Country:US
Mailing Address - Phone:573-324-2656
Mailing Address - Fax:417-944-1440
Practice Address - Street 1:120 1/2 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-1642
Practice Address - Country:US
Practice Address - Phone:573-470-2656
Practice Address - Fax:417-944-1440
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011014526101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1720376916Medicaid
12677303OtherCAQH
1891115036OtherUPPER ROOM NPI