Healthcare Provider Details

I. General information

NPI: 1487279931
Provider Name (Legal Business Name): TYRIK JAMAHL LOCKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 N CEDAR AVE STE 108
FRESNO CA
93726-2538
US

IV. Provider business mailing address

5355 W HOLLAND AVE
FRESNO CA
93722-9162
US

V. Phone/Fax

Practice location:
  • Phone: 559-248-1548
  • Fax:
Mailing address:
  • Phone: 559-644-7544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1487279931
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: