Provider Demographics
NPI:1558899310
Name:BAILEY, MICHAEL CARTER (CAS 1)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CARTER
Last Name:BAILEY
Suffix:
Gender:M
Credentials:CAS 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3503
Mailing Address - Country:US
Mailing Address - Phone:415-858-4249
Mailing Address - Fax:
Practice Address - Street 1:710 C ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3857
Practice Address - Country:US
Practice Address - Phone:415-485-6736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACO41770417101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)