Basic Information
| Provider Information | |||||||||
| NPI: | 1730546706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMICHEAUX | ||||||||
| FirstName: | TAHLIB | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 47825 OASIS ST | ||||||||
| Address2: | |||||||||
| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922016950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608638455 | ||||||||
| FaxNumber: | 7608638587 | ||||||||
| Practice Location | |||||||||
| Address1: | 47825 OASIS ST | ||||||||
| Address2: | |||||||||
| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922016950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608638455 | ||||||||
| FaxNumber: | 7608638587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2016 | ||||||||
| LastUpdateDate: | 01/21/2016 | ||||||||
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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 | 101YM0800X | N257711 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 171M00000X | 01 | CA | MEDICARE | OTHER |