Healthcare Provider Details

I. General information

NPI: 1922290733
Provider Name (Legal Business Name): MISS STACEY ANN CAVANAUGH CERVANTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7080 N MARKS AVE STE 104
FRESNO CA
93711-0288
US

IV. Provider business mailing address

7080 N. MARKS STREET SUITE 104
FRESNO CA
93711
US

V. Phone/Fax

Practice location:
  • Phone: 559-248-8550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number98638
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: