Healthcare Provider Details

I. General information

NPI: 1225695406
Provider Name (Legal Business Name): COURTNEY GIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 07/19/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 POPLAR AVE
MODESTO CA
95354-0510
US

IV. Provider business mailing address

100 POPLAR AVE
MODESTO CA
95354-0510
US

V. Phone/Fax

Practice location:
  • Phone: 209-523-4573
  • Fax:
Mailing address:
  • Phone: 209-523-4573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114715
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: