Healthcare Provider Details

I. General information

NPI: 1417003807
Provider Name (Legal Business Name): MICHAEL JOHN TUCIBAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 N WILLOW AVE STE 142
FRESNO CA
93710-5900
US

IV. Provider business mailing address

6777 N WILLOW AVE STE 142
FRESNO CA
93710-5900
US

V. Phone/Fax

Practice location:
  • Phone: 559-224-7880
  • Fax:
Mailing address:
  • Phone: 559-224-7880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT49368
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberIMF 40986
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: