Healthcare Provider Details

I. General information

NPI: 1083745152
Provider Name (Legal Business Name): MICHAEL SUMMERLIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 W ORANGEWOOD AVE STE. 105
ORANGE CA
92868-2009
US

IV. Provider business mailing address

1940 W ORANGEWOOD AVE STE. 105
ORANGE CA
92868-2009
US

V. Phone/Fax

Practice location:
  • Phone: 714-494-1867
  • Fax:
Mailing address:
  • Phone: 714-494-1867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28000
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number43233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: