Healthcare Provider Details

I. General information

NPI: 1093872095
Provider Name (Legal Business Name): MICHAEL HODSON STREET LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000B S CENTER DR
CLEARLAKE CA
95422-8131
US

IV. Provider business mailing address

6302 13TH AVE
LUCERNE CA
95458
US

V. Phone/Fax

Practice location:
  • Phone: 707-508-6412
  • Fax: 707-274-9192
Mailing address:
  • Phone: 707-274-9101
  • Fax: 707-274-9192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 18551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: