Provider Demographics
NPI:1669701561
Name:OWEN, MICHAEL (SAC-IT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:OWEN
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 N JANACEK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-6102
Mailing Address - Country:US
Mailing Address - Phone:262-641-9050
Mailing Address - Fax:262-641-9126
Practice Address - Street 1:1622 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3014
Practice Address - Country:US
Practice Address - Phone:262-338-9498
Practice Address - Fax:262-338-9506
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15918-130101YA0400X
WI4842101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)