Basic Information
| Provider Information | |||||||||
| NPI: | 1477577971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEST | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6900 GEORGIA AVE NW | ||||||||
| Address2: | WRAMC, ATTN: MCHL-MAO-C | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 203070003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027827341 | ||||||||
| FaxNumber: | 2027827165 | ||||||||
| Practice Location | |||||||||
| Address1: | 6900 GEORGIA AVE NW | ||||||||
| Address2: | WRAMC, BLDG. 6, 3RD FLOOR, DEPT OF PSYCHOLOGY | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 203070003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027825925 | ||||||||
| FaxNumber: | 2027827165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 01/10/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY5707 | FL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | CIGNA | 01 | FL | 18854 | OTHER | 218572 | 01 | FL | HARMONY BEHAVIORAL | OTHER | 54385 | 01 | FL | BCBS OF FLORIDA | OTHER |