Provider Demographics
NPI:1578024857
Name:WELLER, MICHELLE (MT-BC LPMT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:WELLER
Suffix:
Gender:F
Credentials:MT-BC LPMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5333
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02880-5333
Mailing Address - Country:US
Mailing Address - Phone:401-783-4810
Mailing Address - Fax:
Practice Address - Street 1:25 W INDEPENDENCE WAY STE B
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:RI
Practice Address - Zip Code:02881-1127
Practice Address - Country:US
Practice Address - Phone:401-783-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMUS00016225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist