Healthcare Provider Details

I. General information

NPI: 1629164173
Provider Name (Legal Business Name): MICHELLE BEDNARZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 BUCKNAM RD
FALMOUTH ME
04105
US

IV. Provider business mailing address

39 WALLACE AVE.
SO. PORTLAND ME
04106
US

V. Phone/Fax

Practice location:
  • Phone: 207-781-1814
  • Fax:
Mailing address:
  • Phone: 207-761-0650
  • Fax: 207-761-8198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLC540
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: