Provider Demographics
NPI:1144820374
Name:FIDALGO-PENNES, MICHAEL LOUIS
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LOUIS
Last Name:FIDALGO-PENNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 AVERY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01119-1106
Mailing Address - Country:US
Mailing Address - Phone:413-867-8710
Mailing Address - Fax:
Practice Address - Street 1:321 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-1750
Practice Address - Country:US
Practice Address - Phone:508-478-0207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
261QC1500X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health