Provider Demographics
NPI:1336261833
Name:ZIMMERMAN, MICHAEL D (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:642 POLLASKY AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1875
Mailing Address - Country:US
Mailing Address - Phone:559-298-5368
Mailing Address - Fax:559-298-5378
Practice Address - Street 1:642 POLLASKY AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1875
Practice Address - Country:US
Practice Address - Phone:559-298-5368
Practice Address - Fax:559-298-5378
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY10502103T00000X, 103TB0200X, 103TC2200X, 103TF0000X, 103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY105020Medicaid
CA0PL105020Medicare ID - Type Unspecified