Provider Demographics
NPI:1053199612
Name:MATZKE, MICHELLE (MA, LCPC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MATZKE
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 N VILLA LAKE DR STE C
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8290
Mailing Address - Country:US
Mailing Address - Phone:309-713-1485
Mailing Address - Fax:309-419-4328
Practice Address - Street 1:7210 N VILLA LAKE DR STE C
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-8290
Practice Address - Country:US
Practice Address - Phone:309-713-1485
Practice Address - Fax:309-419-4328
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.015318101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health