Provider Demographics
NPI:1245739416
Name:BRADY, MICHELE ELIZABETH (LICSW)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:ELIZABETH
Last Name:BRADY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 SURFSIDE RD
Mailing Address - Street 2:
Mailing Address - City:NANTUCKET
Mailing Address - State:MA
Mailing Address - Zip Code:02554-2862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32 SURFSIDE RD
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-2862
Practice Address - Country:US
Practice Address - Phone:508-648-2028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10234271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1023427OtherLICSW