Provider Demographics
NPI:1316281777
Name:TEBRUGGE, MICHELLE DAWN (MA, LCPC, NCC)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:DAWN
Last Name:TEBRUGGE
Suffix:
Gender:F
Credentials:MA, LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2663 FARRAGUT DR
Mailing Address - Street 2:SUITE A-5
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1462
Mailing Address - Country:US
Mailing Address - Phone:217-899-0108
Mailing Address - Fax:
Practice Address - Street 1:2663 FARRAGUT DR
Practice Address - Street 2:SUITE A-5
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1462
Practice Address - Country:US
Practice Address - Phone:217-899-0108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-24
Last Update Date:2016-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178008478101YM0800X
IL145265246QM0706X
IL180010232101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist