Provider Demographics
NPI:1881089084
Name:PRIDDY, MICHELLE KATHERINE (LCPC, ATC/LAT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KATHERINE
Last Name:PRIDDY
Suffix:
Gender:F
Credentials:LCPC, ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6190 ROCK HALL RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21661-2007
Mailing Address - Country:US
Mailing Address - Phone:410-739-6968
Mailing Address - Fax:
Practice Address - Street 1:125 RUTHSBURG RD.
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617
Practice Address - Country:US
Practice Address - Phone:410-829-8588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC9108101YM0800X
MDA00000142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health