MEDICARE: DR. MARK C MICHAEL PHD, CGP

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	PY00001182	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MI-9953	OTHER	WA	REGENCE BLUE SHIELD

General Provider Information

NPI Number	:	1508864166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK C MICHAEL PHD, CGP

Provider Business Mailing Address
First Line	:	309 FEDERAL AVE E
Second Line	:	STE A
City	:	SEATTLE
State	:	WA
Zip	:	98102-5416
Country	:	US
Telephone Number	:	206-324-8285
Fax Number	:

Provider Business Practice Location Address
First Line	:	309 FEDERAL AVE E
Second Line	:	STE A
City	:	SEATTLE
State	:	WA
Zip	:	98102-5416
Country	:	US
Telephone Number	:	206-324-8285
Fax Number	:

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

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	07/08/2007

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