Provider Demographics
NPI:1528495280
Name:GANTENBEIN, MICHAEL WILLIAM (CADCII (A3518587))
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:GANTENBEIN
Suffix:
Gender:M
Credentials:CADCII (A3518587)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5585 E PACIFIC COAST HIGHWAY
Mailing Address - Street 2:UNIT 166
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804
Mailing Address - Country:US
Mailing Address - Phone:562-498-0768
Mailing Address - Fax:
Practice Address - Street 1:265 SOUTH ANITA DRIVE
Practice Address - Street 2:ORANGE CA
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-978-1090
Practice Address - Fax:714-978-1087
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAADAC A3518587101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)