Healthcare Provider Details

I. General information

NPI: 1457470825
Provider Name (Legal Business Name): SYNCHRONY OF VISALIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 N. DEMAREE ST.
VISALIA CA
93291-4119
US

IV. Provider business mailing address

1041 N. DEMAREE ST.
VISALIA CA
93291-4119
US

V. Phone/Fax

Practice location:
  • Phone: 559-635-4252
  • Fax: 559-635-4281
Mailing address:
  • Phone: 559-635-4252
  • Fax: 559-635-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFC24170
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY18170
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY13698
License Number StateCA

VIII. Authorized Official

Name: DR. EDWYN W ORTIZ-NANCE
Title or Position: CLINICAL DIRECTOR
Credential: PSY.D.
Phone: 559-635-4252