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General NPI Number Information
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NPI Number | 1043384696
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Entity Type | Individual
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Provider Name | MICHELLE DALE LICSW
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Gender | Female
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 04/06/2023
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Provider Practice Location Address
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Address Line | 173 MOUNT AUBURN ST FRNT
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City | WATERTOWN
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State | MA
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Zip | 02472-4005
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Country | US
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Telephone | 857-242-1801
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Fax | 501-617-2087
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Provider Business Mailing Address
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Address Line | 724 POSSUM TROT RD
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City | MALVERN
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State | AR
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Zip | 72104-7819
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Country | US
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Telephone | 501-617-2087
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 11828-C
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 113144
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License Number State | MA
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