Provider Demographics
NPI:1275249054
Name:HEREDIA, LARRY GREGORY (ACSW)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:GREGORY
Last Name:HEREDIA
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 E SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-3928
Mailing Address - Country:US
Mailing Address - Phone:559-304-3287
Mailing Address - Fax:
Practice Address - Street 1:784 W HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-4800
Practice Address - Country:US
Practice Address - Phone:559-538-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87151104100000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker