Provider Demographics
NPI:1427676790
Name:BOBROW, MICHELLE ROSE (RAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSE
Last Name:BOBROW
Suffix:
Gender:F
Credentials:RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 W WEBER AVE STE 129
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-3146
Mailing Address - Country:US
Mailing Address - Phone:209-451-3628
Mailing Address - Fax:209-932-9446
Practice Address - Street 1:445 W WEBER AVE STE 129
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-3146
Practice Address - Country:US
Practice Address - Phone:209-451-3628
Practice Address - Fax:209-932-9446
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390017BN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)