Provider Demographics
NPI:1225103609
Name:WILLINGHAM, MICHELE M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:M
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-4015
Mailing Address - Country:US
Mailing Address - Phone:714-420-1515
Mailing Address - Fax:714-992-5259
Practice Address - Street 1:1619 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-4015
Practice Address - Country:US
Practice Address - Phone:714-420-1515
Practice Address - Fax:714-992-5259
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15849103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP15849AMedicare ID - Type Unspecified