MEDICARE: MICHEL DOUGLAS

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	1041C0700X	Clinical Social Worker	104252	CA

General Provider Information

NPI Number	:	1215309349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHEL DOUGLAS

Provider Business Mailing Address
First Line	:	PO BOX 1802
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94590-0180
Country	:	US
Telephone Number	:	510-877-0687
Fax Number	:

Provider Business Practice Location Address
First Line	:	711 JEFFERSON ST STE 203
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-5556
Country	:	US
Telephone Number	:	707-333-4184
Fax Number	:

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

Provider Enumeration Date	:	10/28/2015
Last Update Date	:	03/06/2023

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