=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023516275
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE CRATE LADC, CCS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2018
-----------------------------------------------------
Last Update Date | 11/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 STATE ST STE 51
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-5113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-356-1455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1620 N MAIN ST
-----------------------------------------------------
City | WINTERPORT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04496-3804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-356-1455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LC5704
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------