Provider Demographics
NPI:1043384696
Name:DALE, MICHELLE (LICSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DALE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:724 POSSUM TROT RD
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-7819
Mailing Address - Country:US
Mailing Address - Phone:501-617-2087
Mailing Address - Fax:
Practice Address - Street 1:173 MOUNT AUBURN ST FRNT
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4005
Practice Address - Country:US
Practice Address - Phone:857-242-1801
Practice Address - Fax:501-617-2087
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR11828-C1041C0700X
MA1131441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP08586OtherBLUE CROSS
MAP23829Medicare ID - Type Unspecified