Basic Information
Provider Information | |||||||||
NPI: | 1588091417 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRIEDLUND | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | BS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | QUINN | ||||||||
OtherFirstName: | MICHELLE | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 210 AVENUE C | ||||||||
Address2: |   | ||||||||
City: | DANVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 618325410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2174423200 | ||||||||
FaxNumber: | 2174427460 | ||||||||
Practice Location | |||||||||
Address1: | 210 AVENUE C | ||||||||
Address2: |   | ||||||||
City: | DANVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 618325410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2174423200 | ||||||||
FaxNumber: | 2174427460 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2013 | ||||||||
LastUpdateDate: | 10/10/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
No ID Information.