Provider Demographics
NPI:1790323640
Name:IANKOWITZ, MICHELLE BETH
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BETH
Last Name:IANKOWITZ
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 1:17200 NEWHOPE ST APT 32A
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4248
Mailing Address - Country:US
Mailing Address - Phone:310-595-8362
Mailing Address - Fax:
Practice Address - Street 1:1000 QUAIL ST STE 175
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2766
Practice Address - Country:US
Practice Address - Phone:310-595-8362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA933481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical