Provider Demographics
NPI:1497100408
Name:BURDICK, MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BURDICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FURNACE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-4721
Mailing Address - Country:US
Mailing Address - Phone:315-794-5199
Mailing Address - Fax:
Practice Address - Street 1:6 FURNACE ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-4721
Practice Address - Country:US
Practice Address - Phone:315-794-5199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0842771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY015224390/1205048832Medicaid