Healthcare Provider Details

I. General information

NPI: 1154907178
Provider Name (Legal Business Name): MARY ELIZABETH MOORADIAN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2021
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 N 1ST ST STE 103
FRESNO CA
93726-0522
US

IV. Provider business mailing address

4820 N 1ST ST STE 103
FRESNO CA
93726-0522
US

V. Phone/Fax

Practice location:
  • Phone: 559-840-2657
  • Fax:
Mailing address:
  • Phone: 559-840-2657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSB94025788
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY33620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: