Provider Demographics
NPI:1245712009
Name:ANDERSEN, MICHELLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 1198
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95812-1198
Mailing Address - Country:US
Mailing Address - Phone:805-242-1043
Mailing Address - Fax:
Practice Address - Street 1:1500 11TH ST # 4774
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-5701
Practice Address - Country:US
Practice Address - Phone:805-242-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30213103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY30213OtherCALIFORNIA BOARD OF PSYCHOLOGY