Provider Demographics
NPI:1770632382
Name:MICHE, MARY (MS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MICHE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 CLEARLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-3722
Mailing Address - Country:US
Mailing Address - Phone:510-845-8417
Mailing Address - Fax:707-263-6666
Practice Address - Street 1:5176 HILL RD E
Practice Address - Street 2:WELLNESS CENTER, SUTTER LAKESIDE HOS
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6300
Practice Address - Country:US
Practice Address - Phone:707-262-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 23075106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 23075OtherSTATE LICENSE