Provider Demographics
NPI:1083830780
Name:GATES, ELIZABETH R (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:GATES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 W NOBLE AVE
Mailing Address - Street 2:PMB 315
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-1662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:631 W WILLOW AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6101
Practice Address - Country:US
Practice Address - Phone:559-738-0800
Practice Address - Fax:559-738-0800
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14743103TC0700X
NY015598-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA49550OtherFRESNO COUNTY VENDOR ID
CAPSY147430Medicaid
CA518693OtherVALUE OPTIONS