Provider Demographics
NPI:1629531926
Name:GIOVANNONI SR, MICHAEL PATRICK
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:GIOVANNONI SR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 LAKEPOINTE DR STE 117
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6425
Mailing Address - Country:US
Mailing Address - Phone:214-379-3300
Mailing Address - Fax:
Practice Address - Street 1:310 HARRIS AVE STE A
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3249
Practice Address - Country:US
Practice Address - Phone:916-649-6793
Practice Address - Fax:916-929-7411
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 106S00000X
CA1699531926101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician