Healthcare Provider Details

I. General information

NPI: 1174016240
Provider Name (Legal Business Name): FRESNO FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 E LOCUST AVE STE 106
FRESNO CA
93720-3000
US

IV. Provider business mailing address

550 W ALLUVIAL AVE STE 108
FRESNO CA
93711-5857
US

V. Phone/Fax

Practice location:
  • Phone: 559-795-5990
  • Fax:
Mailing address:
  • Phone: 559-285-6364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105969
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number104484
License Number StateCA

VIII. Authorized Official

Name: DANIEL MOULTRIE
Title or Position: LMFT
Credential: LMFT
Phone: 559-285-6364