Provider Demographics
NPI:1801311097
Name:MIROUX, MICHAEL E
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:MIROUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 535
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-0535
Mailing Address - Country:US
Mailing Address - Phone:815-875-4548
Mailing Address - Fax:815-875-8602
Practice Address - Street 1:526 S BUREAU VALLEY PKWY STE B
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-2066
Practice Address - Country:US
Practice Address - Phone:815-875-4548
Practice Address - Fax:815-875-8602
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL180.12673101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.012673Medicaid
IL178.013277Medicaid