Healthcare Provider Details

I. General information

NPI: 1275983991
Provider Name (Legal Business Name): JOSHUA BERGONIA ESPANO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 14TH ST
MODESTO CA
95354-2506
US

IV. Provider business mailing address

407 JOSEPH RD
MANTECA CA
95336-3110
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-5401
  • Fax:
Mailing address:
  • Phone: 626-343-0130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number92594
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW71927
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: