Provider Demographics
NPI:1871299842
Name:DAZALLA, MICHELLE ANGELA (AMFT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANGELA
Last Name:DAZALLA
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-5201
Mailing Address - Country:US
Mailing Address - Phone:909-593-2581
Mailing Address - Fax:
Practice Address - Street 1:1350 3RD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5201
Practice Address - Country:US
Practice Address - Phone:909-593-2581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137676106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist