Provider Demographics
NPI:1902005481
Name:STROUT, MICHELLE ((PHD) LICSW)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:STROUT
Suffix:
Gender:F
Credentials:(PHD) LICSW
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 185
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02466-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 BROADWAY
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1734
Practice Address - Country:US
Practice Address - Phone:617-947-8596
Practice Address - Fax:508-822-6509
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10169881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07308OtherBLUE CROSS BLUE SHIELD