Healthcare Provider Details

I. General information

NPI: 1619194347
Provider Name (Legal Business Name): DR. CHARMAINE RADELLANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 N FRESNO ST STE 102
FRESNO CA
93726-4027
US

IV. Provider business mailing address

POST OFFICE BOX 842
FRESNO CA
93712
US

V. Phone/Fax

Practice location:
  • Phone: 559-307-9505
  • Fax:
Mailing address:
  • Phone: 559-307-9505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY22964
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY22964
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY22964
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPSY22964
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY22964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: