Provider Demographics
NPI:1588752083
Name:MICHELSON, MARTIN LOUIS (MA LCPC)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:LOUIS
Last Name:MICHELSON
Suffix:
Gender:M
Credentials:MA LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SOUTH WALNUT STREET
Mailing Address - Street 2:PO BOX 18
Mailing Address - City:ROCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62563
Mailing Address - Country:US
Mailing Address - Phone:217-498-7600
Mailing Address - Fax:
Practice Address - Street 1:201 SOUTH WALNUT STREET
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IL
Practice Address - Zip Code:62563
Practice Address - Country:US
Practice Address - Phone:217-498-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health