Provider Demographics
NPI:1558969048
Name:FRAISE, MYOSHI
Entity Type:Individual
Prefix:
First Name:MYOSHI
Middle Name:
Last Name:FRAISE
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 1:2170 N RANCHO AVE APT H236
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-6941
Mailing Address - Country:US
Mailing Address - Phone:909-743-3306
Mailing Address - Fax:
Practice Address - Street 1:2170 N RANCHO AVE APT H236
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-6941
Practice Address - Country:US
Practice Address - Phone:909-743-3306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3520941106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty