Provider Demographics
NPI:1295390938
Name:MICHELLE GRACA MEDEIROS
Entity type:Organization
Organization Name:MICHELLE GRACA MEDEIROS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDEIROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-830-8334
Mailing Address - Street 1:2975 BOWERS AVE STE 119
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-0955
Mailing Address - Country:US
Mailing Address - Phone:650-830-8334
Mailing Address - Fax:
Practice Address - Street 1:2225 E BAYSHORE RD STE 200
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94303-3220
Practice Address - Country:US
Practice Address - Phone:650-830-8334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty