Provider Demographics
NPI:1861667636
Name:BOREN, MICHELLE (LMHC, LCAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BOREN
Suffix:
Gender:F
Credentials:LMHC, LCAC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:316 LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350
Mailing Address - Country:US
Mailing Address - Phone:219-707-0178
Mailing Address - Fax:219-325-0855
Practice Address - Street 1:316 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350
Practice Address - Country:US
Practice Address - Phone:219-707-0178
Practice Address - Fax:219-325-0855
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000643A101YA0400X
IN39001957A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100163580Medicaid