Healthcare Provider Details

I. General information

NPI: 1629352000
Provider Name (Legal Business Name): MICHAEL DARNEL MCLAIN CCAPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 2ND ST
SAN RAFAEL CA
94901-2712
US

IV. Provider business mailing address

1601 2ND ST
SAN RAFAEL CA
94901-2712
US

V. Phone/Fax

Practice location:
  • Phone: 415-456-6655
  • Fax:
Mailing address:
  • Phone: 415-456-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC055780518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: