Provider Demographics
NPI:1740438779
Name:KLEKOTA-CHISHOLM, MICHELLE L (MA, LMHC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:KLEKOTA-CHISHOLM
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9311 BRIDGEPORT WAY SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1570
Mailing Address - Country:US
Mailing Address - Phone:253-985-5090
Mailing Address - Fax:
Practice Address - Street 1:9311 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1570
Practice Address - Country:US
Practice Address - Phone:253-617-3559
Practice Address - Fax:253-486-1916
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00057820101YM0800X
WALH 60231172101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health