Provider Demographics
NPI:1992804421
Name:SUPPLE, MICHELLE BETH (LMHC)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:BETH
Last Name:SUPPLE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757
Mailing Address - Country:US
Mailing Address - Phone:508-634-1877
Mailing Address - Fax:508-634-1878
Practice Address - Street 1:200 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757
Practice Address - Country:US
Practice Address - Phone:508-634-1877
Practice Address - Fax:508-634-1878
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6080101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2220002001OtherBCBS MA SA
MA1308785OtherMCD MH
M18684OtherBCBS MH
MA1306421Medicaid
MA1306421Medicaid