Healthcare Provider Details

I. General information

NPI: 1144820374
Provider Name (Legal Business Name): MICHAEL LOUIS FIDALGO-PENNES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 FORTUNE BLVD
MILFORD MA
01757-1750
US

IV. Provider business mailing address

92 AVERY ST
SPRINGFIELD MA
01119-1106
US

V. Phone/Fax

Practice location:
  • Phone: 508-478-0207
  • Fax:
Mailing address:
  • Phone: 413-867-8710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: