Provider Demographics
NPI:1912117318
Name:RUNNION, MICHELLE M (MS, LPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:RUNNION
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6233 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7015
Mailing Address - Country:US
Mailing Address - Phone:262-654-1004
Mailing Address - Fax:262-654-6960
Practice Address - Street 1:6233 39TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7015
Practice Address - Country:US
Practice Address - Phone:262-654-1004
Practice Address - Fax:262-654-6960
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12685101YA0400X
WI2989-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39752900Medicaid