Provider Demographics
NPI:1952322489
Name:MONGOLD, MICHAEL RAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAY
Last Name:MONGOLD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2615 TEMPLETON DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-3781
Mailing Address - Country:US
Mailing Address - Phone:530-245-9928
Mailing Address - Fax:530-245-9938
Practice Address - Street 1:1300 WEST ST
Practice Address - Street 2:SUITE D
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1663
Practice Address - Country:US
Practice Address - Phone:530-245-9928
Practice Address - Fax:530-245-9938
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9858103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOPL98580Medicare ID - Type Unspecified