Provider Demographics
NPI:1639775307
Name:DANGOL, MICHELLE A
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:DANGOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 S 174TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-3540
Mailing Address - Country:US
Mailing Address - Phone:402-991-8093
Mailing Address - Fax:
Practice Address - Street 1:5614 FONTENELLE BLVD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68111-1540
Practice Address - Country:US
Practice Address - Phone:952-270-3246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12420101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional