Provider Demographics
NPI:1578790994
Name:MERCURIO, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MERCURIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-0950
Mailing Address - Country:US
Mailing Address - Phone:530-529-9454
Mailing Address - Fax:530-529-9456
Practice Address - Street 1:2608 VICTOR AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1447
Practice Address - Country:US
Practice Address - Phone:530-529-9454
Practice Address - Fax:530-529-9456
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94023330101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94023330OtherPSYCHOLOGIST ASSISTANT