Provider Demographics
NPI:1639407166
Name:MICHAUD, MARION (DSP/CRMA)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:
Last Name:MICHAUD
Suffix:
Gender:F
Credentials:DSP/CRMA
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 214
Mailing Address - Street 2:83 CLEVELAND ROAD
Mailing Address - City:SAINT AGATHA
Mailing Address - State:ME
Mailing Address - Zip Code:04772-0214
Mailing Address - Country:US
Mailing Address - Phone:207-543-6302
Mailing Address - Fax:207-543-6302
Practice Address - Street 1:83 CLEVELAND ROAD
Practice Address - Street 2:
Practice Address - City:SAINT AGATHA
Practice Address - State:ME
Practice Address - Zip Code:04772-0214
Practice Address - Country:US
Practice Address - Phone:207-543-6302
Practice Address - Fax:207-543-6302
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3001860320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities