Provider Demographics
NPI:1033822259
Name:WASIUK, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WASIUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 321
Mailing Address - Street 2:
Mailing Address - City:EAST DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03041-0321
Mailing Address - Country:US
Mailing Address - Phone:978-254-1124
Mailing Address - Fax:
Practice Address - Street 1:1 TARA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03062-2809
Practice Address - Country:US
Practice Address - Phone:603-242-2296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11961101YM0800X
NH2527101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health