MEDICARE: DR. MICHELE R DEANTONI PH.D.

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist	PSY20103	CA
2	103TB0200X	Cognitive & Behavioral Psychologist	PSY20103	CA
3	103TC0700X	Clinical Psychologist	PSY20103	CA
4	103TC1900X	Counseling Psychologist	PSY20103	CA
5	103TC2200X	Clinical Child & Adolescent Psychologist	PSY20103	CA
6	103TF0000X	Family Psychologist	PSY20103	CA
7	103TF0200X	Forensic Psychologist	PSY20103	CA
8	103TH0004X	Health Psychologist	PSY20103	CA
9	103TM1800X	Intellectual & Developmental Disabilities Psychologist	PSY20103	CA

General Provider Information

NPI Number	:	1912178013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELE R DEANTONI PH.D.

Provider Business Mailing Address
First Line	:	374 LEE ST
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-1949
Country	:	US
Telephone Number	:	831-818-0762
Fax Number	:	831-618-4900

Provider Business Practice Location Address
First Line	:	725 FRONT ST
Second Line	:	SUITE 200
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-4538
Country	:	US
Telephone Number	:	831-818-0762
Fax Number	:

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

Provider Enumeration Date	:	03/17/2008
Last Update Date	:	03/17/2008

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