Provider Demographics
NPI:1922556687
Name:SPENCE, MICHAELENE
Entity Type:Individual
Prefix:
First Name:MICHAELENE
Middle Name:
Last Name:SPENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHAELENE
Other - Middle Name:
Other - Last Name:COLESTOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA LADC LPCC
Mailing Address - Street 1:15028 FARNHAM AVE N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-9003
Mailing Address - Country:US
Mailing Address - Phone:651-402-4055
Mailing Address - Fax:
Practice Address - Street 1:15028 FARNHAM AVE N
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-9003
Practice Address - Country:US
Practice Address - Phone:651-402-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301720101YA0400X
MNCC00619101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)