Healthcare Provider Details

I. General information

NPI: 1952322489
Provider Name (Legal Business Name): MICHAEL RAY MONGOLD PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 WEST ST SUITE D
REDDING CA
96001-1663
US

IV. Provider business mailing address

2615 TEMPLETON DR
REDDING CA
96002-3781
US

V. Phone/Fax

Practice location:
  • Phone: 530-245-9928
  • Fax: 530-245-9938
Mailing address:
  • Phone: 530-245-9928
  • Fax: 530-245-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 9858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: