Provider Demographics
NPI:1801943261
Name:DE ANDA, MICHAEL (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DE ANDA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4991 E MCKINLEY AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1900
Mailing Address - Country:US
Mailing Address - Phone:559-251-9290
Mailing Address - Fax:559-251-1137
Practice Address - Street 1:4991 E MCKINLEY AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1900
Practice Address - Country:US
Practice Address - Phone:559-251-9290
Practice Address - Fax:559-251-1137
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS112771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28521ZMedicare PIN