Provider Demographics
NPI:1215494075
Name:PROMESSO, MICHAEL VITO (RASI,RADT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:VITO
Last Name:PROMESSO
Suffix:
Gender:M
Credentials:RASI,RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4404
Mailing Address - Country:US
Mailing Address - Phone:760-745-8478
Mailing Address - Fax:760-745-6852
Practice Address - Street 1:737 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4404
Practice Address - Country:US
Practice Address - Phone:760-745-8478
Practice Address - Fax:760-745-6852
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-P1404240856101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI-P1404240856OtherCCAPP REGISTRATION NUMBER
CARI-P1404240856OtherCCAPP