Provider Demographics
NPI:1467999383
Name:GOODRIE EVANS, MICHELLE (LMFT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GOODRIE EVANS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6977 NAVAJO RD STE 216
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-1503
Mailing Address - Country:US
Mailing Address - Phone:619-206-5929
Mailing Address - Fax:619-600-0683
Practice Address - Street 1:10731 TREENA ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1008
Practice Address - Country:US
Practice Address - Phone:619-600-0683
Practice Address - Fax:619-600-0683
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97524106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist