Provider Demographics
NPI:1588159230
Name:MAMBERG, MICHELLE HOLLY (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:HOLLY
Last Name:MAMBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-2916
Mailing Address - Country:US
Mailing Address - Phone:917-836-9592
Mailing Address - Fax:
Practice Address - Street 1:90 BURRILL AVE RM 315
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324-2728
Practice Address - Country:US
Practice Address - Phone:508-531-2515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10548103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical