Basic Information
| Provider Information | |||||||||
| NPI: | 1801372594 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRESNO COUNTY SUPERINTENDENT OF SCHOOLS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALL 4 YOUTH MENDOTA HUB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2440 TULARE ST. SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594434800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 121 BELMONT AVENUE | ||||||||
| Address2: | |||||||||
| City: | MENDOTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594434800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2018 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | YVETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5593632095 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | 05/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | LEP2596 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | School | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.