Healthcare Provider Details

I. General information

NPI: 1649898735
Provider Name (Legal Business Name): MICHELLE KADLAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 OBERLIN DR STE 300
SAN DIEGO CA
92121-4717
US

IV. Provider business mailing address

1301 E ORANGEWOOD AVE
ANAHEIM CA
92805-6807
US

V. Phone/Fax

Practice location:
  • Phone: 800-249-1266
  • Fax:
Mailing address:
  • Phone: 800-249-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBACB538023
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB538023
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: