Healthcare Provider Details

I. General information

NPI: 1962836908
Provider Name (Legal Business Name): MICHELLE DIANNE CANTRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 E COLORADO BLVD STE 205
PASADENA CA
91101-2028
US

IV. Provider business mailing address

1563 SCENIC DR
PASADENA CA
91103-1937
US

V. Phone/Fax

Practice location:
  • Phone: 571-969-4393
  • Fax:
Mailing address:
  • Phone: 571-969-4393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC12896
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701007352
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPRC200001861
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: