=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861529026
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ROY MICHAELS MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3184 OLD TUNNEL RD
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94549-4153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-932-5072
-----------------------------------------------------
Fax | 925-933-8871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 SADDLE RD.
-----------------------------------------------------
City | WALNUT CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-932-5072
-----------------------------------------------------
Fax | 925-933-8871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MFC20302
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------