Basic Information
Provider Information | |||||||||
NPI: | 1821293200 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HALLADAY | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, LIMHP, LADC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 355 | ||||||||
Address2: |   | ||||||||
City: | SOUTH SIOUX CITY | ||||||||
State: | NE | ||||||||
PostalCode: | 687760355 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024943337 | ||||||||
FaxNumber: | 4024943356 | ||||||||
Practice Location | |||||||||
Address1: | 917 W 21ST ST | ||||||||
Address2: |   | ||||||||
City: | SOUTH SIOUX CITY | ||||||||
State: | NE | ||||||||
PostalCode: | 687762652 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4029493337 | ||||||||
FaxNumber: | 4024943356 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2007 | ||||||||
LastUpdateDate: | 02/04/2014 | ||||||||
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 | 101YM0800X | 1111 | NE | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 886 | NE | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 47083066226 | 05 | NE |   | MEDICAID |