Provider Demographics
NPI:1679750228
Name:SCHAKE, MICHAEL ROBERT (MA LP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:SCHAKE
Suffix:
Gender:M
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 LABREE AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-2819
Mailing Address - Country:US
Mailing Address - Phone:218-681-4240
Mailing Address - Fax:
Practice Address - Street 1:120 LABREE AVE SOUTH
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2819
Practice Address - Country:US
Practice Address - Phone:218-681-4240
Practice Address - Fax:651-645-3534
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0847103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist