Provider Demographics
NPI:1740320852
Name:RODEVICH, MICHAEL ANTHONY (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:RODEVICH
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Gender:M
Credentials:PHD
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Mailing Address - Street 1:375 LAGUNA HONDA BLVD
Mailing Address - Street 2:LAGUNA HONDA HOSPITAL AND REHAB CENTER, MEDICAL SVCS
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-1411
Mailing Address - Country:US
Mailing Address - Phone:415-759-2300
Mailing Address - Fax:415-759-2374
Practice Address - Street 1:375 LAGUNA HONDA BLVD
Practice Address - Street 2:LAGUNA HONDA HOSPITAL AND REHAB CENTER, MEDICAL SVCS
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-1411
Practice Address - Country:US
Practice Address - Phone:415-759-4561
Practice Address - Fax:415-759-4587
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2011-11-01
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Provider Licenses
StateLicense IDTaxonomies
CAPSY14238103G00000X, 103TA0400X, 103TB0200X, 103TC0700X, 103TH0100X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY14238Medicaid
CAPSY14238Medicaid