Healthcare Provider Details

I. General information

NPI: 1174093587
Provider Name (Legal Business Name): VERONICA MARQUEZ MIRANDA SUDCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VERONICA M GOMEZ SUDCC

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 N 1ST ST STE 135&154
FRESNO CA
93726-6800
US

IV. Provider business mailing address

3636 N 1ST ST STE 135&154
FRESNO CA
93726-6800
US

V. Phone/Fax

Practice location:
  • Phone: 559-225-1464
  • Fax: 844-601-2973
Mailing address:
  • Phone: 559-225-1464
  • Fax: 844-601-2973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: