Provider Demographics
NPI:1861984601
Name:MICHAEL EVERSON
Entity type:Organization
Organization Name:MICHAEL EVERSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED MARRIAGE & FAMILY THERAPIS
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT #97556
Authorized Official - Phone:916-905-3395
Mailing Address - Street 1:8037 FAIR OAKS BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-6742
Mailing Address - Country:US
Mailing Address - Phone:916-905-3395
Mailing Address - Fax:916-692-8500
Practice Address - Street 1:8037 FAIR OAKS BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6742
Practice Address - Country:US
Practice Address - Phone:916-905-3395
Practice Address - Fax:916-905-0315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT97556106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALMFT97556OtherCA BOARD OF BEHAVIORAL SERVICES