Provider Demographics
NPI:1063474377
Name:BATES, MICHELLE KATHLYN (MSW)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:KATHLYN
Last Name:BATES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W NC HIGHWAY 54 STE 103
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5572
Mailing Address - Country:US
Mailing Address - Phone:919-354-0840
Mailing Address - Fax:919-748-4441
Practice Address - Street 1:120 CAPCOM AVE STE 101
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6537
Practice Address - Country:US
Practice Address - Phone:919-792-3967
Practice Address - Fax:919-761-5026
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0043571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106594Medicaid