Healthcare Provider Details

I. General information

NPI: 1679601041
Provider Name (Legal Business Name): MIKHAIL GUTKIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MISHA GUTKIN PHD

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 01/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 BROADWAY ST
VALLEJO CA
94589-2226
US

IV. Provider business mailing address

1761 BROADWAY ST
VALLEJO CA
94589-2226
US

V. Phone/Fax

Practice location:
  • Phone: 707-645-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24794
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY24794
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: