Healthcare Provider Details

I. General information

NPI: 1295912988
Provider Name (Legal Business Name): MICHAEL G DESTEFANO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 01/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10333 EL CAMINO REAL
ATASCADERO CA
93422-5808
US

IV. Provider business mailing address

1600 9TH ST ROOM 205 MAILSTOP 2-3
SACRAMENTO CA
95814-6414
US

V. Phone/Fax

Practice location:
  • Phone: 805-468-2000
  • Fax: 805-466-6011
Mailing address:
  • Phone: 916-654-2431
  • Fax: 916-654-3186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 4853
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License NumberPSY 4853
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License NumberPSY 4853
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: