Provider Demographics
NPI:1740513878
Name:CHAZAN, MICHAEL ARIE (PSYD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ARIE
Last Name:CHAZAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN QUENTIN
Mailing Address - State:CA
Mailing Address - Zip Code:94964-1000
Mailing Address - Country:US
Mailing Address - Phone:510-541-9150
Mailing Address - Fax:
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAN QUENTIN
Practice Address - State:CA
Practice Address - Zip Code:94964-1000
Practice Address - Country:US
Practice Address - Phone:510-541-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30887103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist