Healthcare Provider Details

I. General information

NPI: 1487124509
Provider Name (Legal Business Name): MRS. ANGEL MARIE TINDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. ANGEL MARIE CHILD

II. Dates (important events)

Enumeration Date: 12/01/2018
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2772 S. MARTIN LUTHER KING BLVD
FRESNO CA
93706
US

IV. Provider business mailing address

1920 E SUSSEX WAY APT 126
FRESNO CA
93726-3930
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: