Healthcare Provider Details

I. General information

NPI: 1336410141
Provider Name (Legal Business Name): SYNCHRONY OF VISALIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
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 Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY 20528
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY 20528
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY 20528
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY 20528
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY 20528
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPSY 20528
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPSY 20525
License Number StateCA
# 8
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 20528
License Number StateCA

VIII. Authorized Official

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