Healthcare Provider Details

I. General information

NPI: 1427783232
Provider Name (Legal Business Name): MICHAEL RAYMOND HEGARTY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 POTRERO AVENUE BUILDING 90, 5TH FLOOR (WD95)
SAN FRANCISCO CA
94110-1509
US

IV. Provider business mailing address

995 POTRERO AVENUE BUILDING 90, 5TH FLOOR (WD95)
SAN FRANCISCO CA
94110-1509
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-3848
  • Fax:
Mailing address:
  • Phone: 628-206-3848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberR1475550722
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: