Provider Demographics
NPI:1861023095
Name:CERMAK, MICHELLE L
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:CERMAK
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 1:11115 W DANA LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-3639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11115 W DANA LN
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-3639
Practice Address - Country:US
Practice Address - Phone:623-330-7206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-18560101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional