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General NPI Number Information
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NPI Number | 1215769104
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Entity Type | Organization
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Legal Business Name | VITALIZE A PROFESSIONAL PSYCHOLOGY CORPORATION
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Dates
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Enumeration Date | 08/19/2024
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Last Update Date | 08/19/2024
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Provider Practice Location Address
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Address Line | 155 E SHAW AVE STE 201
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City | FRESNO
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State | CA
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Zip | 93710-7619
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Country | US
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Telephone | 559-492-1560
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Fax | 559-234-0641
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Provider Business Mailing Address
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Address Line | 155 E SHAW AVE STE 201
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City | FRESNO
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State | CA
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Zip | 93710-7619
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Country | US
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Telephone | 559-492-1560
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Fax | 559-234-0641
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Authorized Official
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Title or Position | CEO
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Name | DR. JONATHON BAIRD
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Credential | PSYD
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Telephone | 559-797-0116
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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