Healthcare Provider Details

I. General information

NPI: 1538440755
Provider Name (Legal Business Name): PROMESA BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 G ST
MERCED CA
95340-2133
US

IV. Provider business mailing address

7475 N PALM AVE STE 107
FRESNO CA
93711-5763
US

V. Phone/Fax

Practice location:
  • Phone: 209-725-3114
  • Fax: 209-725-3114
Mailing address:
  • Phone: 559-439-5437
  • Fax: 559-439-5411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1044
License Number StateCA

VIII. Authorized Official

Name: LISA WEIGANT
Title or Position: CEO
Credential: MA
Phone: 559-439-5437