Healthcare Provider Details

I. General information

NPI: 1801171939
Provider Name (Legal Business Name): MICHELLE NICOLE ISLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10526 DUBNOFF WAY
NORTH HOLLYWOOD CA
91606-3921
US

IV. Provider business mailing address

4222 MAYBANK AVE
LAKEWOOD CA
90712-3910
US

V. Phone/Fax

Practice location:
  • Phone: 562-676-6698
  • Fax:
Mailing address:
  • Phone: 562-676-6698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: