Provider Demographics
NPI:1952580847
Name:BERUBE, MICHELLE J (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:J
Last Name:BERUBE
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 1:272 MAIN ST
Mailing Address - Street 2:MADAWASKA
Mailing Address - City:MADAWASKA
Mailing Address - State:ME
Mailing Address - Zip Code:04756-1126
Mailing Address - Country:US
Mailing Address - Phone:207-436-9587
Mailing Address - Fax:
Practice Address - Street 1:272 MAIN ST
Practice Address - Street 2:MADAWASKA
Practice Address - City:MADAWASKA
Practice Address - State:ME
Practice Address - Zip Code:04756-1126
Practice Address - Country:US
Practice Address - Phone:207-436-9587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC117631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432729699Medicaid