Provider Demographics
NPI:1073968780
Name:SERVIN, MICHELLE (R1193480315)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SERVIN
Suffix:
Gender:F
Credentials:R1193480315
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3548 ATCHISON CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5166
Mailing Address - Country:US
Mailing Address - Phone:951-256-6843
Mailing Address - Fax:
Practice Address - Street 1:802 MAGNOLIA AVE STE 202
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3144
Practice Address - Country:US
Practice Address - Phone:951-686-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-01
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)