Basic Information
| Provider Information | |||||||||
| NPI: | 1598286791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAUD | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2394 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602005419 | ||||||||
| FaxNumber: | 3602006736 | ||||||||
| Practice Location | |||||||||
| Address1: | 1616 S. GOLD ST. #4 | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608074929 | ||||||||
| FaxNumber: | 3608074160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2017 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60944835 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2130057 | 05 | WA | MEDICAID |