=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922702612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY TIME MENTAL HEALTH, A PROFESSIONAL PSYCHOLOGY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2023
-----------------------------------------------------
Last Update Date | 03/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7045 N FRUIT AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93711-0761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-666-6550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1781 E FIR AVE STE 102
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93720-3865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | NICHOLAS BEETS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-933-1931
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------