Provider Demographics
NPI:1922398809
Name:DIFFENBAUGH, MICHELLE MARIE (LADC)
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:MARIE
Last Name:DIFFENBAUGH
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1885 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 246
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:612-326-7563
Mailing Address - Fax:651-647-9147
Practice Address - Street 1:1885 UNIVERSITY AVE
Practice Address - Street 2:SUITE 246
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3489
Practice Address - Country:US
Practice Address - Phone:612-326-7563
Practice Address - Fax:651-647-9147
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302501101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)