Provider Demographics
NPI:1750474086
Name:PINKSTON, MICHAEL R (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:PINKSTON
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 1:862 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4529
Mailing Address - Country:US
Mailing Address - Phone:707-575-7230
Mailing Address - Fax:707-575-1513
Practice Address - Street 1:862 3RD ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4529
Practice Address - Country:US
Practice Address - Phone:707-575-7230
Practice Address - Fax:707-575-1513
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4719103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPF0047190Medicaid
CAPF0047190Medicaid