Healthcare Provider Details

I. General information

NPI: 1275249054
Provider Name (Legal Business Name): LARRY GREGORY HEREDIA ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 08/07/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 W HOLLAND AVE
CLOVIS CA
93612-4800
US

IV. Provider business mailing address

736 E SIERRA AVE
FRESNO CA
93710-3928
US

V. Phone/Fax

Practice location:
  • Phone: 559-538-1230
  • Fax:
Mailing address:
  • Phone: 559-304-3287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number87151
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: