Provider Demographics
NPI:1841292471
Name:HUSTON, MICHAEL LEE (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:HUSTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 INGERSOLL AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-3534
Mailing Address - Country:US
Mailing Address - Phone:515-279-6200
Mailing Address - Fax:515-279-4528
Practice Address - Street 1:3900 INGERSOLL AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-3534
Practice Address - Country:US
Practice Address - Phone:515-279-6200
Practice Address - Fax:515-279-4528
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00675103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0249649Medicaid
IA0249649Medicaid
IAI18250Medicare PIN