Provider Demographics
NPI:1063628238
Name:DUCKWORTH, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:DUCKWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7299 N CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-0487
Mailing Address - Country:US
Mailing Address - Phone:559-268-1466
Mailing Address - Fax:559-268-1302
Practice Address - Street 1:22368 S. SIXTH
Practice Address - Street 2:
Practice Address - City:S. DOS PALOS
Practice Address - State:CA
Practice Address - Zip Code:93665
Practice Address - Country:US
Practice Address - Phone:559-268-1466
Practice Address - Fax:559-258-1302
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24004APOtherSUBSTANCE ABUSE