Basic Information
| Provider Information | |||||||||
| NPI: | 1750752887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RATHFELDER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1925 HAYES AVE | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448704737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195575177 | ||||||||
| FaxNumber: | 4195575179 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 BUCKEYE BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT CLINTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434521423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197342942 | ||||||||
| FaxNumber: | 4197344922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2015 | ||||||||
| LastUpdateDate: | 10/15/2015 | ||||||||
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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 | 104100000X | S1501167 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 104100000X | 05 | OH | MEDICAID |