Provider Demographics
NPI:1376936336
Name:FRY, MICHELLE NICOLE (MA, CRC, LPC)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:NICOLE
Last Name:FRY
Suffix:
Gender:F
Credentials:MA, CRC, LPC
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:NICOLE
Other - Last Name:RUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CRC
Mailing Address - Street 1:498 THUNDERBIRD TRL
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-1584
Mailing Address - Country:US
Mailing Address - Phone:630-347-2925
Mailing Address - Fax:
Practice Address - Street 1:4110 LITT DR
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-1120
Practice Address - Country:US
Practice Address - Phone:708-547-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00116763101Y00000X
IL178.009665101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor