Provider Demographics
NPI:1154816411
Name:PROMESA BEHAVIORAL HEALTH-SPRUCE
Entity Type:Organization
Organization Name:PROMESA BEHAVIORAL HEALTH-SPRUCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:559-439-5437
Mailing Address - Street 1:7120 N MARKS AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-0268
Mailing Address - Country:US
Mailing Address - Phone:559-341-2394
Mailing Address - Fax:
Practice Address - Street 1:775 E SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:559-439-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-28
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100406294320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101044Medicaid