1356925325 NPI number — DESERT RIVER PSYCHOLOGY, INC.

Table of content: (NPI 1356925325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356925325 NPI number — DESERT RIVER PSYCHOLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT RIVER PSYCHOLOGY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356925325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4781 E GETTYSBURG AVE #101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93726-1814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-472-8375
Provider Business Mailing Address Fax Number:
888-466-8290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4781 E GETTYSBURG AVE #101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93726-1814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-472-8375
Provider Business Practice Location Address Fax Number:
888-466-8290
Provider Enumeration Date:
05/06/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BACA MORGAN
Authorized Official First Name:
ALEXIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PSYCHOLOGIST/PRESIDENT
Authorized Official Telephone Number:
559-472-8375

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5593142 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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