Basic Information
| Provider Information | |||||||||
| NPI: | 1538506399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENKE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364124 | ||||||||
| FaxNumber: | 5136364283 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364124 | ||||||||
| FaxNumber: | 5136364283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2013 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | S.1302299 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 34006723A | IN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | I.1302299-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.