Healthcare Provider Details

I. General information

NPI: 1023730629
Provider Name (Legal Business Name): MARIA D SALAS RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/15/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2772 S. MARTIN LUTHER KING BLVD.
FRESNO CA
93706
US

IV. Provider business mailing address

445 BROOKS DR APT C
LEMOORE CA
93245-3871
US

V. Phone/Fax

Practice location:
  • Phone: 559-265-4800
  • Fax:
Mailing address:
  • Phone: 559-205-4661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1460610322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: