Provider Demographics
NPI:1548728629
Name:BAZAL, MICHELLE MARIE (LAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:BAZAL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:EYL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:CO LAKE REGION HUMAN SERVICE CENTER
Mailing Address - Street 2:200 HWY 2 WEST
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-3532
Mailing Address - Country:US
Mailing Address - Phone:701-665-2200
Mailing Address - Fax:701-665-2300
Practice Address - Street 1:200 HIGHWAY 2 W
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-3532
Practice Address - Country:US
Practice Address - Phone:701-665-2200
Practice Address - Fax:701-665-2300
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1848171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator