Provider Demographics
NPI:1609954528
Name:TRASK, MICHELLE D (MSW)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:D
Last Name:TRASK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 S BONHAM RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-4004
Mailing Address - Country:US
Mailing Address - Phone:803-404-2064
Mailing Address - Fax:
Practice Address - Street 1:1821 PICKENS ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2630
Practice Address - Country:US
Practice Address - Phone:803-404-2064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC92151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD011543600Medicaid