Healthcare Provider Details

I. General information

NPI: 1336665074
Provider Name (Legal Business Name): MICHELLE AHN MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 08/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 ADDISON ST STE 113
BERKELEY CA
94702
US

IV. Provider business mailing address

1376 HOPKINS ST
BERKELEY CA
94702
US

V. Phone/Fax

Practice location:
  • Phone: 510-788-0582
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA121280
License Number StateCA

VIII. Authorized Official

Name: MICHELLE AHN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 510-788-0582