Provider Demographics
NPI:1457363749
Name:PERRY, MICHAELA M (LICSW)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:M
Last Name:PERRY
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:PO BOX 899
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813-0899
Mailing Address - Country:US
Mailing Address - Phone:401-364-7705
Mailing Address - Fax:401-364-9104
Practice Address - Street 1:4705A OLD POST ROAD
Practice Address - Street 2:SOUTH SHORE MENTAL HEALTH CENTER
Practice Address - City:CHARLESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02813-1819
Practice Address - Country:US
Practice Address - Phone:401-364-7705
Practice Address - Fax:401-364-9104
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC42481041C0700X
RIISW018341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME404960099Medicaid