Provider Demographics
NPI:1407548118
Name:CONVERSE, MICHAELLA MARANDA
Entity Type:Individual
Prefix:
First Name:MICHAELLA
Middle Name:MARANDA
Last Name:CONVERSE
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 1:10707 BROOKEMEADE CIR APT 2
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21795-1457
Mailing Address - Country:US
Mailing Address - Phone:240-938-9837
Mailing Address - Fax:
Practice Address - Street 1:5300 WESTVIEW DR STE 200
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8303
Practice Address - Country:US
Practice Address - Phone:240-242-5865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician