Provider Demographics
NPI:1720157571
Name:ANDERSON, MICHAELEEN MCMAHON (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAELEEN
Middle Name:MCMAHON
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1608
Mailing Address - Country:US
Mailing Address - Phone:631-981-4419
Mailing Address - Fax:631-981-4419
Practice Address - Street 1:991 MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1608
Practice Address - Country:US
Practice Address - Phone:631-981-4419
Practice Address - Fax:631-981-4419
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045247-1101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health