Provider Demographics
NPI:1104604610
Name:BOODRY, MICHELLE L (LPC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:BOODRY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W8040 RANDALLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-9451
Mailing Address - Country:US
Mailing Address - Phone:920-979-7855
Mailing Address - Fax:
Practice Address - Street 1:W8040 RANDALLWOOD LN
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-9451
Practice Address - Country:US
Practice Address - Phone:920-979-7855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5821--125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty