Provider Demographics
NPI:1902488679
Name:CARLYLE, MICHAEL (CADC-CS, ICCS, CCDS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CARLYLE
Suffix:
Gender:M
Credentials:CADC-CS, ICCS, CCDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28184 TIERRA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-3075
Mailing Address - Country:US
Mailing Address - Phone:949-228-8478
Mailing Address - Fax:
Practice Address - Street 1:28184 TIERRA VISTA RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-3075
Practice Address - Country:US
Practice Address - Phone:949-228-8478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACS0920517101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty