Provider Demographics
NPI:1174209472
Name:STANTON, MICHAEL VICENTE (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VICENTE
Last Name:STANTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1271 WASHINGTON AVE STE 123
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-3646
Mailing Address - Country:US
Mailing Address - Phone:415-689-4535
Mailing Address - Fax:
Practice Address - Street 1:25800 CARLOS BEE BLVD BLDG STE 502
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94542-3000
Practice Address - Country:US
Practice Address - Phone:415-689-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27402103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical