Provider Demographics
NPI:1891034096
Name:NOLL, MICHAEL W (LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:NOLL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:WILLIAM
Other - Last Name:NOLL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:1477 KENWOOD DR STE 104
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1160
Mailing Address - Country:US
Mailing Address - Phone:920-215-1553
Mailing Address - Fax:920-821-1432
Practice Address - Street 1:1477 KENWOOD DR STE 104
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1160
Practice Address - Country:US
Practice Address - Phone:920-215-1553
Practice Address - Fax:920-821-1432
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
WI5752101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100028111Medicaid