Provider Demographics
NPI:1962968263
Name:STOCKWELL, MICHELLE (TCADC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:STOCKWELL
Suffix:
Gender:F
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 ALBIA RD
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-3907
Mailing Address - Country:US
Mailing Address - Phone:641-682-8772
Mailing Address - Fax:641-682-1924
Practice Address - Street 1:1527 ALBIA RD
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-3907
Practice Address - Country:US
Practice Address - Phone:641-682-8772
Practice Address - Fax:641-682-1924
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAT19000101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1659353670Medicaid