MEDICARE: DESERT RIVER PSYCHOLOGY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356925325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT RIVER PSYCHOLOGY, INC.

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

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

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

Provider Enumeration Date	:	05/06/2021
Last Update Date	:	05/06/2021

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