Provider Demographics
NPI:1013412915
Name:GAUDET, MICHELLE MARIE (MED, LABA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:GAUDET
Suffix:
Gender:F
Credentials:MED, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SW CUTOFF
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-2730
Mailing Address - Country:US
Mailing Address - Phone:508-341-2829
Mailing Address - Fax:508-459-9360
Practice Address - Street 1:330 SOUTHWEST CUTOFF
Practice Address - Street 2:SUITE 203
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604
Practice Address - Country:US
Practice Address - Phone:508-341-2829
Practice Address - Fax:508-459-9360
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-24
Last Update Date:2018-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2206103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst