Healthcare Provider Details

I. General information

NPI: 1336392778
Provider Name (Legal Business Name): SUSHANA RACHELLE TAMAMIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 02/11/2022
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3467 W SHAW AVE SUITE # 102
FRESNO CA
93711-3223
US

IV. Provider business mailing address

3989 N ANGUS ST
FRESNO CA
93726-4204
US

V. Phone/Fax

Practice location:
  • Phone: 559-274-0299
  • Fax: 559-274-0292
Mailing address:
  • Phone: 559-288-4709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number30052
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: