Healthcare Provider Details

I. General information

NPI: 1104757608
Provider Name (Legal Business Name): JOSHUA MCILLWAIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
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: 559-600-9180
  • Fax:
Mailing address:
  • Phone: 559-600-4439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number161614
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: