Healthcare Provider Details

I. General information

NPI: 1083121982
Provider Name (Legal Business Name): MICHELLE SYLVIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 DOWD RD
BANGOR ME
04401-6700
US

IV. Provider business mailing address

74 DOWD RD
BANGOR ME
04401-6700
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-6800
  • Fax: 207-947-6872
Mailing address:
  • Phone: 207-947-6800
  • Fax: 207-947-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAC6281
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: