Healthcare Provider Details

I. General information

NPI: 1780184606
Provider Name (Legal Business Name): OMEGA MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2018
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2549 W SHAW AVE
FRESNO CA
93711-3308
US

IV. Provider business mailing address

2549 W SHAW AVE
FRESNO CA
93711-3308
US

V. Phone/Fax

Practice location:
  • Phone: 559-412-7799
  • Fax: 559-412-7799
Mailing address:
  • Phone: 559-412-7799
  • Fax: 559-241-0105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: BEN JOHNSON
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 559-412-7799