Basic Information
| Provider Information | |||||||||
| NPI: | 1063474377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | KATHLYN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 W NC HIGHWAY 54 STE 103 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277075572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193540840 | ||||||||
| FaxNumber: | 9197484441 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 CAPCOM AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275876537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197923967 | ||||||||
| FaxNumber: | 9197615026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C004357 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6106594 | 05 | NC | MEDICAID |