Provider Demographics
NPI:1871102947
Name:CLEARY, MICHELLE D (R1233040616)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:CLEARY
Suffix:
Gender:F
Credentials:R1233040616
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 194
Mailing Address - Street 2:
Mailing Address - City:CROWS LANDING
Mailing Address - State:CA
Mailing Address - Zip Code:95313-0194
Mailing Address - Country:US
Mailing Address - Phone:209-210-0545
Mailing Address - Fax:
Practice Address - Street 1:1405 11TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0748
Practice Address - Country:US
Practice Address - Phone:209-284-0970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1233040616101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)