Provider Demographics
NPI:1386133098
Name:WHEAT, MICHAELA ROSE
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:ROSE
Last Name:WHEAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 25TH ST NE APT 2114
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3979
Mailing Address - Country:US
Mailing Address - Phone:219-263-9177
Mailing Address - Fax:
Practice Address - Street 1:4160 OCOEE ST N STE 8
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4886
Practice Address - Country:US
Practice Address - Phone:423-362-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health