Basic Information
Provider Information
NPI: 1003003344
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SUGARMAN
FirstName: MICHAEL
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1411 E 31ST
Address2:  
City: OAKLAND
State: CA
PostalCode: 94602
CountryCode: US
TelephoneNumber: 5104376471
FaxNumber: 5104374613
Practice Location
Address1: 15400 FOOTHILL BLVD
Address2:  
City: SAN LEANDRO
State: CA
PostalCode: 94578
CountryCode: US
TelephoneNumber: 5108954343
FaxNumber: 5108954333
Other Information
ProviderEnumerationDate: 10/01/2007
LastUpdateDate: 10/01/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X  Y Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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