Basic Information
| Provider Information | |||||||||
| NPI: | 1356545008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LY | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | CHAU | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NGUYEN | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | CHAU | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 652 FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943012622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504841493 | ||||||||
| FaxNumber: | 6503231720 | ||||||||
| Practice Location | |||||||||
| Address1: | 652 FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943012622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504841493 | ||||||||
| FaxNumber: | 6503231720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | A8558131 | 01 | CA | CA DRIVER LICENSE | OTHER |