Provider Demographics
NPI:1639901317
Name:MICHALAK, COURTNEY MARIE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MARIE
Last Name:MICHALAK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 WOOD FORGE CIR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-8559
Mailing Address - Country:US
Mailing Address - Phone:513-518-7882
Mailing Address - Fax:
Practice Address - Street 1:5720 GATEWAY STE 204
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-1891
Practice Address - Country:US
Practice Address - Phone:513-445-9959
Practice Address - Fax:513-725-1276
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2405983-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0062663Medicaid
16284816OtherCAQH