Healthcare Provider Details

I. General information

NPI: 1558699678
Provider Name (Legal Business Name): MICHELLE OWUSU PCCI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 2
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

9825 MAGNOLIA AVE STE B
RIVERSIDE CA
92503-3565
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2499
  • Fax:
Mailing address:
  • Phone: 951-509-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4500
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180007353
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: