Provider Demographics
NPI:1538296132
Name:MICALE, CONNIE ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:ANNE
Last Name:MICALE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MITCHELL DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1314
Mailing Address - Country:US
Mailing Address - Phone:415-254-6565
Mailing Address - Fax:
Practice Address - Street 1:2750 N TEXAS ST
Practice Address - Street 2:SUITE 430
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-1290
Practice Address - Country:US
Practice Address - Phone:707-429-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA205971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical