Provider Demographics
NPI:1295075463
Name:GASPAR, MICHELLE NELSON (MED)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:NELSON
Last Name:GASPAR
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:NELSON
Other - Last Name:WELLINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:94 ADAMS LN
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04429-4169
Mailing Address - Country:US
Mailing Address - Phone:509-222-4837
Mailing Address - Fax:888-331-5464
Practice Address - Street 1:268 STATE ST STE 2-3
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5417
Practice Address - Country:US
Practice Address - Phone:509-222-4837
Practice Address - Fax:888-331-5464
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LH60970859101YM0800X
MECC5352101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health