MEDICARE: SEQUOIA PSYCHOTHERAPY CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TP2701X	Group Psychotherapy Psychologist	PSY 13574	CA

General Provider Information

NPI Number	:	1427085349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEQUOIA PSYCHOTHERAPY CENTER, INC

Provider Business Mailing Address
First Line	:	1960 N. GATEWAY BLVD
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93727
Country	:	US
Telephone Number	:	559-266-5200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1960 N. GATEWAY BLVD
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93727
Country	:	US
Telephone Number	:	559-266-5200
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE CLINICAL DIRECTOR
Name	:	DR. MARK DAVID POPPER
Credential	:	PH.D.
Telephone Number	:	559-266-5200

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	03/29/2019

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