Provider Demographics
NPI:1922556687
Name:COLESTOCK, MICHAELENE (LADC, LPCC)
Entity type:Individual
Prefix:
First Name:MICHAELENE
Middle Name:
Last Name:COLESTOCK
Suffix:
Gender:F
Credentials:LADC, LPCC
Other - Prefix:
Other - First Name:MICHAELENE
Other - Middle Name:
Other - Last Name:SPENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA LADC LPCC
Mailing Address - Street 1:4365 OAKMEDE LN
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR TOWNSHIP
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7606
Mailing Address - Country:US
Mailing Address - Phone:651-402-4055
Mailing Address - Fax:
Practice Address - Street 1:445 ETNA ST STE 55
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-5848
Practice Address - Country:US
Practice Address - Phone:651-756-8561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301720101YA0400X
MNCC00619101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)