Basic Information
| Provider Information | |||||||||
| NPI: | 1609269711 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAUD | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | CL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOURGOIN | ||||||||
| OtherFirstName: | KAYLA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW-CC, MHRT-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 180 ACADEMY ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047693183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075542352 | ||||||||
| FaxNumber: | 2075542351 | ||||||||
| Practice Location | |||||||||
| Address1: | 88 FOX ST | ||||||||
| Address2: | |||||||||
| City: | MADAWASKA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077286727 | ||||||||
| FaxNumber: | 2077287679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2015 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | MC17407 | ME | N | Behavioral Health & Social Service Providers | Social Worker | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | LC19264 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.