Provider Demographics
NPI:1790311041
Name:MCMICHAEL, AMY VAN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:VAN
Last Name:MCMICHAEL
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 1:1820 PALOPINTO AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-3827
Mailing Address - Country:US
Mailing Address - Phone:626-354-7019
Mailing Address - Fax:
Practice Address - Street 1:527 E ROWLAND ST STE 112
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3230
Practice Address - Country:US
Practice Address - Phone:626-428-7683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53679106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist