Basic Information
| Provider Information | |||||||||
| NPI: | 1992951222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLYCARPE | ||||||||
| FirstName: | YAZMIN | ||||||||
| MiddleName: | BETZAIDA | ||||||||
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| Credential: | LPHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 E MERCED ST | ||||||||
| Address2: | |||||||||
| City: | FOWLER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936252316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598929452 | ||||||||
| FaxNumber: | 5596271405 | ||||||||
| Practice Location | |||||||||
| Address1: | 5150 N 6TH ST STE 169 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937107505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593132185 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | ASW106166 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.