Provider Demographics
NPI:1063771863
Name:CARLISH, MICHAEL ALAN (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALAN
Last Name:CARLISH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1611 S MELROSE DR
Mailing Address - Street 2:SUITE A # 251
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-5407
Mailing Address - Country:US
Mailing Address - Phone:760-749-1410
Mailing Address - Fax:760-749-3347
Practice Address - Street 1:50100 GOLSH RD
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082-5338
Practice Address - Country:US
Practice Address - Phone:760-749-1410
Practice Address - Fax:760-749-3347
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24938103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical