Provider Demographics
NPI:1053127597
Name:MACINNIS, MICHELLE LEE (LLPC, MS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:MACINNIS
Suffix:
Gender:F
Credentials:LLPC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46540 BARTLETT DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1517
Mailing Address - Country:US
Mailing Address - Phone:313-282-0384
Mailing Address - Fax:
Practice Address - Street 1:41100 PLYMOUTH RD STE 110
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-3895
Practice Address - Country:US
Practice Address - Phone:734-927-1201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451024061101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty