Healthcare Provider Details

I. General information

NPI: 1538417449
Provider Name (Legal Business Name): MISS GE HER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 E DAKOTA AVE
FRESNO CA
93726-4821
US

IV. Provider business mailing address

1925 E DAKOTA AVE
FRESNO CA
93726-4821
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-9171
  • Fax:
Mailing address:
  • Phone: 559-600-9171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW105627
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: