Provider Demographics
NPI:1093872095
Name:STREET, MICHAEL HODSON (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HODSON
Last Name:STREET
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6302 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:LUCERNE
Mailing Address - State:CA
Mailing Address - Zip Code:95458
Mailing Address - Country:US
Mailing Address - Phone:707-274-9101
Mailing Address - Fax:707-274-9192
Practice Address - Street 1:7000B S CENTER DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8131
Practice Address - Country:US
Practice Address - Phone:707-508-6412
Practice Address - Fax:707-274-9192
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 185511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical