Provider Demographics
NPI:1689550600
Name:ANDERSON, MICHELLE MARIE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13440 VENTURA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-6158
Mailing Address - Country:US
Mailing Address - Phone:818-960-6030
Mailing Address - Fax:
Practice Address - Street 1:15972 TUSCOLA RD STE 103
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2106
Practice Address - Country:US
Practice Address - Phone:760-242-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician