Provider Demographics
NPI:1699290924
Name:GEOGHEGAN, MICHAEL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GEOGHEGAN
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MAY ST
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-5520
Mailing Address - Country:US
Mailing Address - Phone:508-838-2250
Mailing Address - Fax:
Practice Address - Street 1:200 MAY ST
Practice Address - Street 2:
Practice Address - City:SOUTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703
Practice Address - Country:US
Practice Address - Phone:508-761-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN217504163W00000X
MARN2318977363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse