Provider Demographics
NPI:1477191716
Name:EVANS-ZEPEDA, MICHAEL D (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:EVANS-ZEPEDA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N MICHAEL AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-2411
Mailing Address - Country:US
Mailing Address - Phone:310-428-3705
Mailing Address - Fax:
Practice Address - Street 1:13200 CROSSROADS PKWY N STE 350
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91746-3496
Practice Address - Country:US
Practice Address - Phone:562-821-1491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94024891103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty