Provider Demographics
NPI:1285981779
Name:EDDY, MICHELLE R (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:R
Last Name:EDDY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 LARSEN RD STE 216
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-4863
Mailing Address - Country:US
Mailing Address - Phone:920-883-6995
Mailing Address - Fax:920-496-6009
Practice Address - Street 1:2701 LARSEN RD STE 216
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4863
Practice Address - Country:US
Practice Address - Phone:920-883-6995
Practice Address - Fax:920-496-6009
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6671-123101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100027601Medicaid