Provider Demographics
NPI:1558610881
Name:BURGESS, MICHELE ANN MATHIEU (LSW-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:ANN MATHIEU
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 RIVERSIDE STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103
Mailing Address - Country:US
Mailing Address - Phone:207-871-1211
Mailing Address - Fax:207-871-1232
Practice Address - Street 1:9 HILLCREST AVENUE
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:ME
Practice Address - Zip Code:04346
Practice Address - Country:US
Practice Address - Phone:207-582-9205
Practice Address - Fax:207-582-9653
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX13488104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker