Provider Demographics
NPI:1013107135
Name:CHANGARIS, MICHAEL CHRISTOPHER (PSYD LIC#:PSY24712)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHRISTOPHER
Last Name:CHANGARIS
Suffix:
Gender:M
Credentials:PSYD LIC#:PSY24712
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 SAN LUIS RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-2001
Mailing Address - Country:US
Mailing Address - Phone:510-214-2559
Mailing Address - Fax:
Practice Address - Street 1:771 SAN LUIS RD
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2001
Practice Address - Country:US
Practice Address - Phone:510-214-2559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24712103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist