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General NPI Number Information
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NPI Number | 1902267008
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Entity Type | Individual
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Provider Name | MICHAEL GENE IDIART JR. PH.D.
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Gender | Male
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Dates
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Enumeration Date | 03/16/2016
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Last Update Date | 01/12/2024
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Provider Practice Location Address
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Address Line | 23370 ROAD 22
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City | CHOWCHILLA
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State | CA
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Zip | 93610-8504
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Country | US
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Telephone | 559-655-5531
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Fax |
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Provider Business Mailing Address
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Address Line | 1544 E LESTER AVE
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City | FRESNO
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State | CA
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Zip | 93720-1996
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Country | US
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Telephone | 559-655-5531
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TF0200X
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Taxonomy Name | Forensic Psychologist
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License Number |
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY29830
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License Number State | CA
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