Healthcare Provider Details

I. General information

NPI: 1760942379
Provider Name (Legal Business Name): MICAH LINTON PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 20TH ST STE 540
SANTA MONICA CA
90404-2118
US

IV. Provider business mailing address

635 CRESTMOORE PL
VENICE CA
90291-4814
US

V. Phone/Fax

Practice location:
  • Phone: 310-582-7612
  • Fax: 424-277-6342
Mailing address:
  • Phone: 310-621-8203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY30784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: