Provider Demographics
NPI:1336784545
Name:WAACK, MICHELLE L (MAC, LPC, CSAC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:L
Last Name:WAACK
Suffix:
Gender:F
Credentials:MAC, LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 MAIN ST STE 120
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-1337
Mailing Address - Country:US
Mailing Address - Phone:920-288-2846
Mailing Address - Fax:920-770-4153
Practice Address - Street 1:1270 MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-1337
Practice Address - Country:US
Practice Address - Phone:920-288-2846
Practice Address - Fax:920-770-4153
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16594-132101YA0400X
WI8568-125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100095134Medicaid