Provider Demographics
NPI:1679962351
Name:KAMRAVA, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KAMRAVA
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 1:3835 N FREEWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1954
Mailing Address - Country:US
Mailing Address - Phone:916-576-7900
Mailing Address - Fax:
Practice Address - Street 1:1019 GAYLEY AVE FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3437
Practice Address - Country:US
Practice Address - Phone:424-273-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-17
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97639106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist