Provider Demographics
NPI:1235746843
Name:DEGERNESS, MICHELE (MHRS)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:DEGERNESS
Suffix:
Gender:F
Credentials:MHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 SAFFLOWER PL
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-4611
Mailing Address - Country:US
Mailing Address - Phone:916-470-3597
Mailing Address - Fax:
Practice Address - Street 1:423 SAFFLOWER PL
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-4611
Practice Address - Country:US
Practice Address - Phone:916-470-3597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2024-06-17
Deactivation Date:2024-04-10
Deactivation Code:
Reactivation Date:2024-05-03
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
CAPSB94027126103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101Y00000XOtherEL HOGAR