MEDICARE: DR. J. MICHAEL PRIDDY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY10186	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSY10186	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1144283466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. J. MICHAEL PRIDDY PHD

Provider Business Mailing Address
First Line	:	1 BAYWOOD AVE
Second Line	:	SUITE 7
City	:	SAN MATEO
State	:	CA
Zip	:	94402-1523
Country	:	US
Telephone Number	:	701-255-9279
Fax Number	:	701-222-4142

Provider Business Practice Location Address
First Line	:	1801 BUSH ST
Second Line	:	SUITE 111
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-5239
Country	:	US
Telephone Number	:	415-752-2726
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	07/08/2007

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