Provider Demographics
NPI:1053973206
Name:CHIDESTER, MICHAEL LEE JR (CATC-I)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEE
Last Name:CHIDESTER
Suffix:JR
Gender:M
Credentials:CATC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 THORNTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-3734
Mailing Address - Country:US
Mailing Address - Phone:510-792-4357
Mailing Address - Fax:510-745-1693
Practice Address - Street 1:6330 THORNTON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-3734
Practice Address - Country:US
Practice Address - Phone:510-792-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YA0400XOtherSUD