Healthcare Provider Details

I. General information

NPI: 1366186405
Provider Name (Legal Business Name): ITZAMARY XIMENA TIRADO MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2719 N AIR FRESNO DR
FRESNO CA
93727-1547
US

IV. Provider business mailing address

2719 N AIR FRESNO DR
FRESNO CA
93727-1547
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-8918
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW105983
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: