Provider Demographics
NPI:1649386277
Name:ZEDALIS, MICHELLE C (LMHC)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:C
Last Name:ZEDALIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 PARK AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1953
Mailing Address - Country:US
Mailing Address - Phone:508-753-2900
Mailing Address - Fax:
Practice Address - Street 1:255 PARK AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1953
Practice Address - Country:US
Practice Address - Phone:508-753-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5880101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2220002001OtherBCBS SA
MA1308785OtherMCD MH
MA1308785OtherMCD MH
MA1306421Medicaid