Healthcare Provider Details

I. General information

NPI: 1215769104
Provider Name (Legal Business Name): VITALIZE A PROFESSIONAL PSYCHOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E SHAW AVE STE 201
FRESNO CA
93710-7619
US

IV. Provider business mailing address

155 E SHAW AVE STE 201
FRESNO CA
93710-7619
US

V. Phone/Fax

Practice location:
  • Phone: 559-492-1560
  • Fax: 559-234-0641
Mailing address:
  • Phone: 559-492-1560
  • Fax: 559-234-0641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHON BAIRD
Title or Position: CEO
Credential: PSYD
Phone: 559-797-0116