Provider Demographics
NPI:1144990961
Name:DETRICK, MICHAELA J (LPC, CAADC)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:J
Last Name:DETRICK
Suffix:
Gender:F
Credentials:LPC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 N LOYALSOCK AVE
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-1022
Mailing Address - Country:US
Mailing Address - Phone:570-220-5460
Mailing Address - Fax:
Practice Address - Street 1:1521 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-5426
Practice Address - Country:US
Practice Address - Phone:570-322-5051
Practice Address - Fax:570-322-6788
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC013722101YM0800X, 101YP2500X
PA10091101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)