Provider Demographics
NPI:1710155171
Name:MICHAELS, MARK H (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:MICHAELS
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 1:110 PINE AVE.
Mailing Address - Street 2:#1070
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802
Mailing Address - Country:US
Mailing Address - Phone:562-212-6500
Mailing Address - Fax:866-212-2809
Practice Address - Street 1:110 PINE AVE.
Practice Address - Street 2:#1070
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802
Practice Address - Country:US
Practice Address - Phone:562-212-6500
Practice Address - Fax:866-212-2809
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14795103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY14795OtherLICENSE #