Provider Demographics
NPI:1902860588
Name:WINE, MICHELLE DAWN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:DAWN
Last Name:WINE
Suffix:
Gender:F
Credentials:PSYD
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Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR BLDG 7505
Mailing Address - Street 2:ATTN: TIFARRAH WILSON, CREDENTIAL TECHNICIAN
Mailing Address - City:FT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4613
Mailing Address - Country:US
Mailing Address - Phone:719-526-7461
Mailing Address - Fax:719-526-7132
Practice Address - Street 1:1650 COCHRANE CIR BLDG 7505
Practice Address - Street 2:ATTN: TIFARRAH WILSON, CREDENTIAL TECHNICIAN
Practice Address - City:FT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-526-7461
Practice Address - Fax:719-526-7132
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO3193103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical