=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336261833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL D. ZIMMERMAN PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 02/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 642 POLLASKY AVE SUITE 210
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93612-1875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-298-5368
-----------------------------------------------------
Fax | 559-298-5378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 642 POLLASKY AVE SUITE 210
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93612-1875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-298-5368
-----------------------------------------------------
Fax | 559-298-5378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY10502
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TB0200X
-----------------------------------------------------
Taxonomy Name | Cognitive & Behavioral Psychologist
-----------------------------------------------------
License Number | PSY10502
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PSY10502
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TF0000X
-----------------------------------------------------
Taxonomy Name | Family Psychologist
-----------------------------------------------------
License Number | PSY10502
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103TF0200X
-----------------------------------------------------
Taxonomy Name | Forensic Psychologist
-----------------------------------------------------
License Number | PSY10502
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY10502
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------