Provider Demographics
NPI:1013743715
Name:MOGENROS, MICHELLE RENEA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEA
Last Name:MOGENROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENEA
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8294 N CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:ALTAMONT
Mailing Address - State:IL
Mailing Address - Zip Code:62411-3545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 BALL ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-1344
Practice Address - Country:US
Practice Address - Phone:465-476-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10327814103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool