Provider Demographics
NPI:1750398194
Name:WEBER, MICHELLE R (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:R
Last Name:WEBER
Suffix:
Gender:F
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:PO BOX 133
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95696-0133
Mailing Address - Country:US
Mailing Address - Phone:707-718-2758
Mailing Address - Fax:
Practice Address - Street 1:595 BUCK AVE STE G
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3642
Practice Address - Country:US
Practice Address - Phone:707-718-2758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18534103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA295995OtherMHN
CA295995OtherMHN
CAQ00343Medicare UPIN