Provider Demographics
NPI:1255478608
Name:PAGE, MICHAEL PELAN (LICSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PELAN
Last Name:PAGE
Suffix:
Gender:M
Credentials:LICSW
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 350
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02651-0350
Mailing Address - Country:US
Mailing Address - Phone:774-722-3040
Mailing Address - Fax:
Practice Address - Street 1:543 NORTH ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-2766
Practice Address - Country:US
Practice Address - Phone:508-984-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1029798101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP20884Medicare ID - Type Unspecified