Provider Demographics
NPI:1124597794
Name:VISAYA, MICHELLE ANDREA
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANDREA
Last Name:VISAYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANDREA
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 MENSCH CT APT C
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-3207
Mailing Address - Country:US
Mailing Address - Phone:209-294-8455
Mailing Address - Fax:
Practice Address - Street 1:6400 TUPELO DR
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-1741
Practice Address - Country:US
Practice Address - Phone:916-729-3098
Practice Address - Fax:916-729-3006
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician