Provider Demographics
NPI:1073030896
Name:POW-ANPONGKUL, MICHELLE LIN (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LIN
Last Name:POW-ANPONGKUL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4858 W PICO BLVD STE 325
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-4225
Mailing Address - Country:US
Mailing Address - Phone:310-751-0552
Mailing Address - Fax:
Practice Address - Street 1:4760 SEPULVEDA BLVD.
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230
Practice Address - Country:US
Practice Address - Phone:310-390-6612
Practice Address - Fax:310-398-5690
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84555104100000X
171M00000X, 390200000X
CA991111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program