Basic Information
| Provider Information | |||||||||
| NPI: | 1902860588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COCHRANE CIR BLDG 7505 | ||||||||
| Address2: | ATTN: TIFARRAH WILSON, CREDENTIAL TECHNICIAN | ||||||||
| City: | FT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267461 | ||||||||
| FaxNumber: | 7195267132 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 COCHRANE CIR BLDG 7505 | ||||||||
| Address2: | ATTN: TIFARRAH WILSON, CREDENTIAL TECHNICIAN | ||||||||
| City: | FT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267461 | ||||||||
| FaxNumber: | 7195267132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3193 | CO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.