Provider Demographics
NPI:1013501162
Name:WAYMAN, MICHELLE GLENN (LPCC, LAC, NCC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GLENN
Last Name:WAYMAN
Suffix:
Gender:F
Credentials:LPCC, LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2487 S GILBERT RD STE 106-140
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-2805
Mailing Address - Country:US
Mailing Address - Phone:480-608-5655
Mailing Address - Fax:
Practice Address - Street 1:2525 RAYWOOD VIEW
Practice Address - Street 2:APT 933
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920
Practice Address - Country:US
Practice Address - Phone:480-608-5655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0018489101YM0800X
AZLAC-19074101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health