Healthcare Provider Details

I. General information

NPI: 1346094729
Provider Name (Legal Business Name): CALIFORNIA CONSORTIUM FOR PREVENTION AND INTERVENTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 N FINE AVE
FRESNO CA
93727-1510
US

IV. Provider business mailing address

16183 SAMPLE RD
CLOVIS CA
93619-9708
US

V. Phone/Fax

Practice location:
  • Phone: 559-813-0461
  • Fax:
Mailing address:
  • Phone: 559-813-0461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MITCHEL C CASADOS
Title or Position: CEO/DIRECTOR
Credential: PHD
Phone: 559-813-0461