Basic Information
| Provider Information | |||||||||
| NPI: | 1144809161 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POVERELLO HOUSE ENRICHMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 412 F ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937063409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594986988 | ||||||||
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| Practice Location | |||||||||
| Address1: | 412 F ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937063409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594986988 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2021 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | DARRAH | ||||||||
| AuthorizedOfficialFirstName: | ZACH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5592831006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.