Provider Demographics
NPI:1174016240
Name:FRESNO FAMILY THERAPY
Entity Type:Organization
Organization Name:FRESNO FAMILY THERAPY
Other - Org Name:FRESNO FAMILY THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LMFT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOULTRIE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:559-285-6364
Mailing Address - Street 1:550 W ALLUVIAL AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-5857
Mailing Address - Country:US
Mailing Address - Phone:559-285-6364
Mailing Address - Fax:
Practice Address - Street 1:745 E LOCUST AVE STE 106
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3000
Practice Address - Country:US
Practice Address - Phone:559-795-5990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104484106H00000X
CA105969106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UNKNOWNOtherUNKNOWN