Provider Demographics
NPI:1285205450
Name:CHAN, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CHAN
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 1:368 VETERANS MEMORIAL HWY STE 3
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4322
Mailing Address - Country:US
Mailing Address - Phone:631-533-0315
Mailing Address - Fax:
Practice Address - Street 1:368 VETERANS MEMORIAL HWY STE 3
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4322
Practice Address - Country:US
Practice Address - Phone:631-533-0315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013920101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health