Provider Demographics
NPI:1316322936
Name:RISKIN, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RISKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 EAST 17TH ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705
Mailing Address - Country:US
Mailing Address - Phone:714-953-9882
Mailing Address - Fax:714-953-2094
Practice Address - Street 1:1913 EAST 17TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:714-953-9882
Practice Address - Fax:714-953-2094
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM8768101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health