Provider Demographics
NPI:1255765749
Name:LIVELY, MICHELLE MARIE (LSW)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:LIVELY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 COLFAX AVE N
Mailing Address - Street 2:130
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-1402
Mailing Address - Country:US
Mailing Address - Phone:651-222-0757
Mailing Address - Fax:
Practice Address - Street 1:227 COLFAX AVE N
Practice Address - Street 2:130
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-1402
Practice Address - Country:US
Practice Address - Phone:651-222-0757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program