Provider Demographics
NPI:1467008813
Name:CHAVEZ, MICHELLE CONCEPCION
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CONCEPCION
Last Name:CHAVEZ
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 1:2127 MCPHERSON PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-3823
Mailing Address - Country:US
Mailing Address - Phone:213-219-4249
Mailing Address - Fax:
Practice Address - Street 1:17727 E CYPRESS ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-2634
Practice Address - Country:US
Practice Address - Phone:626-858-4920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13342-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty