Healthcare Provider Details

I. General information

NPI: 1194674366
Provider Name (Legal Business Name): MICHELLE COMMUNITY COUNSELING AVEDISSIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2026
Last Update Date: 01/22/2026
Certification Date: 01/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 E 6TH ST # 95376
TRACY CA
95376-4107
US

IV. Provider business mailing address

19 E 6TH ST # 95376
TRACY CA
95376-4107
US

V. Phone/Fax

Practice location:
  • Phone: 209-835-8583
  • Fax: 209-835-8583
Mailing address:
  • Phone: 209-835-8583
  • Fax: 209-835-8583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101200000X
TaxonomyDrama Therapist
License NumberAMFT158008
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: