Provider Demographics
NPI:1982933230
Name:TERRY-DAVID, MICHELLE (MSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TERRY-DAVID
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 COMMERCIAL ST.
Mailing Address - Street 2:#19 MYSTIC VALLEY ELDER SERVICES
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148
Mailing Address - Country:US
Mailing Address - Phone:781-388-4823
Mailing Address - Fax:781-324-1369
Practice Address - Street 1:300 COMMERCIAL ST.
Practice Address - Street 2:#19 MYSTIC VALLEY ELDER SERVICES
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148
Practice Address - Country:US
Practice Address - Phone:781-388-4823
Practice Address - Fax:781-324-1369
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10242971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical