Provider Demographics
NPI:1740428853
Name:DAGUE, MICHELLE (LCSW, QMHP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DAGUE
Suffix:
Gender:F
Credentials:LCSW, QMHP
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 13537
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-1537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:503-200-1302
Practice Address - Street 1:388 STATE ST STE 445
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3927
Practice Address - Country:US
Practice Address - Phone:503-884-3946
Practice Address - Fax:503-200-1302
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL53191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500800774Medicaid