Provider Demographics
NPI:1427786763
Name:BURNSIDE, MICHELE
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:BURNSIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 ASH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:MI
Mailing Address - Zip Code:48457-7724
Mailing Address - Country:US
Mailing Address - Phone:810-272-1379
Mailing Address - Fax:
Practice Address - Street 1:24681 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2305
Practice Address - Country:US
Practice Address - Phone:833-328-8476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-14
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst