Provider Demographics
NPI:1417003807
Name:TUCIBAT, MICHAEL JOHN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:TUCIBAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6777 N WILLOW AVE STE 142
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5900
Mailing Address - Country:US
Mailing Address - Phone:559-224-7880
Mailing Address - Fax:
Practice Address - Street 1:6777 N WILLOW AVE STE 142
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5900
Practice Address - Country:US
Practice Address - Phone:559-224-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 40986225400000X
CALMFT49368106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner