Basic Information
| Provider Information | |||||||||
| NPI: | 1063563146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RASMUSSEN | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAYS | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1440 | ||||||||
| Address2: | |||||||||
| City: | WAUTOMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549821440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207875514 | ||||||||
| FaxNumber: | 9207874737 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S TOWNLINE RD | ||||||||
| Address2: | |||||||||
| City: | WAUTOMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207875514 | ||||||||
| FaxNumber: | 9207874737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3540-125 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 3540-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 40988300 | 05 | WI | MEDICAID |