Provider Demographics
NPI:1477918035
Name:MICHELSON, MICHELE ELISE (LBA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:ELISE
Last Name:MICHELSON
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 N VIOLET ST
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5124
Mailing Address - Country:US
Mailing Address - Phone:516-473-9298
Mailing Address - Fax:
Practice Address - Street 1:39 N VIOLET ST
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5124
Practice Address - Country:US
Practice Address - Phone:516-473-9298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000620103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst