Healthcare Provider Details

I. General information

NPI: 1891508248
Provider Name (Legal Business Name): MISAEL PELAYO PPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2025
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 VAN NESS AVE
FRESNO CA
93721-2002
US

IV. Provider business mailing address

624 E ADAMS AVE
FOWLER CA
93625-2111
US

V. Phone/Fax

Practice location:
  • Phone: 559-234-3000
  • Fax:
Mailing address:
  • Phone: 558-834-6080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number240087012
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: