Provider Demographics
NPI:1851435929
Name:AYRES, MICHELLE (LLC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:AYRES
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 WIRTH CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704
Mailing Address - Country:US
Mailing Address - Phone:608-556-8432
Mailing Address - Fax:
Practice Address - Street 1:8415 ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4601
Practice Address - Country:US
Practice Address - Phone:703-208-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI893-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1245786680Medicaid