Provider Demographics
NPI:1801578281
Name:VICTORIA MICHACA, MISAEL G
Entity type:Individual
Prefix:
First Name:MISAEL
Middle Name:G
Last Name:VICTORIA MICHACA
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 1:21550 BOX SPRINGS RD APT 1080
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-6715
Mailing Address - Country:US
Mailing Address - Phone:951-502-4664
Mailing Address - Fax:
Practice Address - Street 1:1902 ORANGE TREE LN STE 200
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2800
Practice Address - Country:US
Practice Address - Phone:909-798-6200
Practice Address - Fax:909-798-6210
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program