MEDICARE: PROMESA BEHAVIORAL HEALTH

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	251S00000X	Community/Behavioral Health Agency	101044	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558667410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROMESA BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	7475 N PALM AVE STE 107
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93711-5763
Country	:	US
Telephone Number	:	559-439-5437
Fax Number	:	559-439-5411

Provider Business Practice Location Address
First Line	:	6425 W. BOWLES
Second Line	:
City	:	RAISIN CITY
State	:	CA
Zip	:	93652-0069
Country	:	US
Telephone Number	:	559-233-0128
Fax Number	:	559-486-0891

Authorized Official
Title or Position	:	CEO
Name	:	LISA WEIGANT
Credential	:	MA
Telephone Number	:	559-439-5437

Provider Enumeration Date	:	02/09/2011
Last Update Date	:	02/09/2011

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Directions to “PROMESA BEHAVIORAL HEALTH ” Practice Location

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