Provider Demographics
NPI:1508864166
Name:MICHAEL, MARK C (PHD, CGP)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:PHD, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 FEDERAL AVE E
Mailing Address - Street 2:STE A
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-5416
Mailing Address - Country:US
Mailing Address - Phone:206-324-8285
Mailing Address - Fax:
Practice Address - Street 1:309 FEDERAL AVE E
Practice Address - Street 2:STE A
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-5416
Practice Address - Country:US
Practice Address - Phone:206-324-8285
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001182103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMI-9953OtherREGENCE BLUE SHIELD
R12192Medicare UPIN