Provider Demographics
NPI:1831517630
Name:WATHEN, MICHAEL (MA, LCPC, CAADC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WATHEN
Suffix:
Gender:M
Credentials:MA, LCPC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 S CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2207
Mailing Address - Country:US
Mailing Address - Phone:309-287-5270
Mailing Address - Fax:
Practice Address - Street 1:210 N HAMMES AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6680
Practice Address - Country:US
Practice Address - Phone:815-322-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2019-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011043101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional