Provider Demographics
NPI:1962454728
Name:MICHIELUTTE, WILLIAM L (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:L
Last Name:MICHIELUTTE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3779 VEST MILL RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2991
Mailing Address - Country:US
Mailing Address - Phone:336-768-9264
Mailing Address - Fax:
Practice Address - Street 1:3779 VEST MILL RD
Practice Address - Street 2:SUITE C
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2991
Practice Address - Country:US
Practice Address - Phone:336-768-9264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC577103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2810124Medicare ID - Type Unspecified