Provider Demographics
NPI:1225604861
Name:MICHIELS, MARISA BERGFIELD (MA)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:BERGFIELD
Last Name:MICHIELS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:BERGFIELD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:146 W RIVER ST STE 11A
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2609
Practice Address - Country:US
Practice Address - Phone:401-793-8770
Practice Address - Fax:401-793-8709
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS02209103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical