Provider Demographics
NPI:1558901546
Name:MAGGIORE, MISTY A
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:A
Last Name:MAGGIORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2719 N AIR FRESNO DR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1547
Mailing Address - Country:US
Mailing Address - Phone:559-600-9180
Mailing Address - Fax:
Practice Address - Street 1:4417 E INYO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-2977
Practice Address - Country:US
Practice Address - Phone:559-600-9180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1261000817101YA0400X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)