Provider Demographics
NPI:1487835203
Name:STANFILL, MICHAEL LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:STANFILL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4461 PARK BLVD
Mailing Address - Street 2:#4
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4098
Mailing Address - Country:US
Mailing Address - Phone:480-206-8425
Mailing Address - Fax:
Practice Address - Street 1:11878 AVENUE OF INDUSTRY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3423
Practice Address - Country:US
Practice Address - Phone:858-675-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60273012103T00000X, 103TA0400X, 103TC0700X, 103TC2200X, 103TB0200X, 103TF0200X, 103TP2701X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPY60273012OtherPSYCHOLOGY LICENSE