Provider Demographics
NPI:1629296140
Name:LONDON, MICHELE LAKS (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LAKS
Last Name:LONDON
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 1:2658 DEL MAR HEIGHTS RD
Mailing Address - Street 2:#306
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-3100
Mailing Address - Country:US
Mailing Address - Phone:619-990-5406
Mailing Address - Fax:
Practice Address - Street 1:12520 HIGH BLUFF DR
Practice Address - Street 2:#135
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2041
Practice Address - Country:US
Practice Address - Phone:858-602-2416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2011-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 61501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABSLCS061500OtherBLUE SHIELD OF CALIFORNIA
CABSLCS061500OtherBLUE SHIELD OF CALIFORNIA