Healthcare Provider Details

I. General information

NPI: 1649198250
Provider Name (Legal Business Name): MICHELLE HANNEMANN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 E AVENIDA SAN GABRIEL APT 4
SAN CLEMENTE CA
92672-3228
US

IV. Provider business mailing address

114 E AVENIDA SAN GABRIEL APT 4
SAN CLEMENTE CA
92672-3228
US

V. Phone/Fax

Practice location:
  • Phone: 714-717-8388
  • Fax:
Mailing address:
  • Phone: 714-717-8388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHELLE HANNEMANN
Title or Position: LICENSED PSYCHOLOGIST
Credential: PSY.D.
Phone: 714-717-8388