Basic Information
| Provider Information | |||||||||
| NPI: | 1134667215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEARNS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1931 CENTER ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947041105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106669552 | ||||||||
| FaxNumber: | 5106669087 | ||||||||
| Practice Location | |||||||||
| Address1: | 1931 CENTER ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947041105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106669552 | ||||||||
| FaxNumber: | 5106669087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2017 | ||||||||
| LastUpdateDate: | 02/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 00 | 01 | CA | 00 | OTHER |