Provider Demographics
NPI:1104457373
Name:HINKLE, MICHELE MARIA (BSIS)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARIA
Last Name:HINKLE
Suffix:
Gender:F
Credentials:BSIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:JIM THORPE
Mailing Address - State:PA
Mailing Address - Zip Code:18229-1203
Mailing Address - Country:US
Mailing Address - Phone:213-697-8287
Mailing Address - Fax:
Practice Address - Street 1:410 E GARDEN AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2941
Practice Address - Country:US
Practice Address - Phone:213-697-8287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID171M00000X, 222Q00000X, 171M00000X, 251S00000X
261QM0855X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1104457373Medicaid