Healthcare Provider Details

I. General information

NPI: 1881479004
Provider Name (Legal Business Name): MICHELLE M LEPAK LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CORPORATE PLAZA DR STE 150
NEWPORT BEACH CA
92660-7952
US

IV. Provider business mailing address

11 ALASSIO
IRVINE CA
92620-2569
US

V. Phone/Fax

Practice location:
  • Phone: 714-651-6369
  • Fax:
Mailing address:
  • Phone: 714-651-6369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number4321
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: