Provider Demographics
NPI:1043025174
Name:ZUMKELLER, MICHAEL LEWIS (R1592701224)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEWIS
Last Name:ZUMKELLER
Suffix:
Gender:M
Credentials:R1592701224
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 GREENBRIER AVE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4406
Mailing Address - Country:US
Mailing Address - Phone:209-273-6265
Mailing Address - Fax:
Practice Address - Street 1:2251 PALM AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1814
Practice Address - Country:US
Practice Address - Phone:209-273-6265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR15992701224101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)