Provider Demographics
NPI:1073368031
Name:CONDERMAN, MICHELLE RENEE (LSW, CADC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:CONDERMAN
Suffix:
Gender:
Credentials:LSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 IL ROUTE 2
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-9118
Mailing Address - Country:US
Mailing Address - Phone:815-973-1077
Mailing Address - Fax:
Practice Address - Street 1:325 IL ROUTE 2
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9118
Practice Address - Country:US
Practice Address - Phone:815-973-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL37961101YA0400X
IL150107507104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)