Provider Demographics
NPI:1114491545
Name:GERAGHTY, MICHAEL E (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:GERAGHTY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:E
Other - Last Name:GERAGHTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:35620 DESERT ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2904
Mailing Address - Country:US
Mailing Address - Phone:951-409-1750
Mailing Address - Fax:
Practice Address - Street 1:35620 DESERT ROSE WAY
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-2904
Practice Address - Country:US
Practice Address - Phone:951-409-1750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical