Provider Demographics
NPI:1154919199
Name:YODER, MICHAEL ALVIN (CADC -II #A051150519)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALVIN
Last Name:YODER
Suffix:
Gender:M
Credentials:CADC -II #A051150519
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 CALLE GRANDE VIS
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3541
Mailing Address - Country:US
Mailing Address - Phone:949-558-4606
Mailing Address - Fax:
Practice Address - Street 1:3004 CALLE GRANDE VIS
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3541
Practice Address - Country:US
Practice Address - Phone:949-558-4606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA051150519101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA051150519OtherCADC-II