Provider Demographics
NPI:1346908167
Name:HEALE, A PROFESSIONAL LICENSED CLINICAL SOCIAL WORK CORPORATION
Entity Type:Organization
Organization Name:HEALE, A PROFESSIONAL LICENSED CLINICAL SOCIAL WORK CORPORATION
Other - Org Name:HEALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:209-450-8037
Mailing Address - Street 1:3848 MCHENRY AVE STE 135-123
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-1586
Mailing Address - Country:US
Mailing Address - Phone:209-450-8037
Mailing Address - Fax:
Practice Address - Street 1:420 DOWNEY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1301
Practice Address - Country:US
Practice Address - Phone:209-450-8037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-30
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700125705Medicaid