Healthcare Provider Details

I. General information

NPI: 1811993389
Provider Name (Legal Business Name): MICHAEL J GILEWSKI PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11406 LOMA LINDA DR RM 105
LOMA LINDA CA
92354-3711
US

IV. Provider business mailing address

11406 LOMA LINDA DR RM 105
LOMA LINDA CA
92354-3711
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-6220
  • Fax: 909-558-6278
Mailing address:
  • Phone: 909-558-6220
  • Fax: 909-558-6278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY 9194
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPSY 9194
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY 9194
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: