Basic Information
| Provider Information | |||||||||
| NPI: | 1346781671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOX | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITNEY | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | N82W18281 WILLIAMSBURG CT | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530513525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628258906 | ||||||||
| FaxNumber: | 4142666238 | ||||||||
| Practice Location | |||||||||
| Address1: | 1655 W MEQUON RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530923254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622409744 | ||||||||
| FaxNumber: | 2622409745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2017 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5284-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1346781671 | 05 | WI | MEDICAID |