Provider Demographics
NPI:1063131845
Name:ANDREW, MICHELE PARK (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:PARK
Last Name:ANDREW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 GLENN PL
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3170
Mailing Address - Country:US
Mailing Address - Phone:925-366-5255
Mailing Address - Fax:
Practice Address - Street 1:1830 GLENN PL
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3170
Practice Address - Country:US
Practice Address - Phone:925-366-5255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1080001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical