Provider Demographics
NPI:1528100641
Name:MATTHEWS, MICHELLE M (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3341 N 85TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3708
Mailing Address - Country:US
Mailing Address - Phone:414-837-5227
Mailing Address - Fax:
Practice Address - Street 1:4109 67TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3836
Practice Address - Country:US
Practice Address - Phone:262-652-9830
Practice Address - Fax:262-652-2931
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7334-1231041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43739800Medicaid