Healthcare Provider Details

I. General information

NPI: 1538646625
Provider Name (Legal Business Name): METAMORPHOSIS THERAPY GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2193 E ECLIPSE AVE
FRESNO CA
93720-4616
US

IV. Provider business mailing address

2193 E ECLIPSE AVE
FRESNO CA
93720-4616
US

V. Phone/Fax

Practice location:
  • Phone: 559-906-8058
  • Fax:
Mailing address:
  • Phone: 559-906-8058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-9569
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number17021
License Number StateCA

VIII. Authorized Official

Name: COURTNEY GEBHART
Title or Position: CFO
Credential: CCC-SLP
Phone: 559-906-8058