Provider Demographics
NPI:1609583624
Name:BLACKMORE, MICHELLE (COUNSELOR INTERN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BLACKMORE
Suffix:
Gender:F
Credentials:COUNSELOR INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 TAFT RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:MA
Mailing Address - Zip Code:01564-2117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72 JACQUES AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2476
Practice Address - Country:US
Practice Address - Phone:508-860-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program