Provider Demographics
NPI:1326639956
Name:PHOMMACHIT, MICHELLE LANE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LANE
Last Name:PHOMMACHIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39663 LESLIE ST APT 424
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-2243
Mailing Address - Country:US
Mailing Address - Phone:408-707-7122
Mailing Address - Fax:
Practice Address - Street 1:2035 FAIRMONT DR # SR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1088
Practice Address - Country:US
Practice Address - Phone:866-866-7496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11468101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)