Provider Demographics
NPI:1760185730
Name:MENOS, MICHELANDE ISME
Entity Type:Individual
Prefix:
First Name:MICHELANDE
Middle Name:ISME
Last Name:MENOS
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 1:32627 WAUKETA DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-3293
Mailing Address - Country:US
Mailing Address - Phone:586-748-9223
Mailing Address - Fax:
Practice Address - Street 1:38219 MOUND RD STE 102
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-3466
Practice Address - Country:US
Practice Address - Phone:313-550-0847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-23-278455106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician