Healthcare Provider Details

I. General information

NPI: 1801166525
Provider Name (Legal Business Name): EVA BARANOFF MCKENZIE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 QUEBEC AVENUE
CORCORAN CA
93212-9715
US

IV. Provider business mailing address

3223 N DE WOLF AVE
FRESNO CA
93737-9717
US

V. Phone/Fax

Practice location:
  • Phone: 559-992-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY9694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: