Provider Demographics
NPI:1639293624
Name:DISHON, MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DISHON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CENTURY PARK E
Mailing Address - Street 2:STE. 906
Mailing Address - City:CENTURY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-475-4640
Mailing Address - Fax:310-475-4640
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:STE. 906
Practice Address - City:CENTURY CITY
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-475-4640
Practice Address - Fax:310-475-4640
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7689103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist