Provider Demographics
NPI:1871681940
Name:ANTHONY, MICHAEL RAYMOND (PSYD; QME)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:PSYD; QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 MAIN STREET
Mailing Address - Street 2:#24
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648
Mailing Address - Country:US
Mailing Address - Phone:714-317-0168
Mailing Address - Fax:949-281-5268
Practice Address - Street 1:18800 DELAWARE STREET
Practice Address - Street 2:SUITE 400
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648
Practice Address - Country:US
Practice Address - Phone:714-317-0168
Practice Address - Fax:949-281-5268
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA#PSY17717103TC0700X
CA17717103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical