Provider Demographics
NPI:1588824619
Name:QUALLE, CORDIE MICAH (LMFT)
Entity Type:Individual
Prefix:MR
First Name:CORDIE
Middle Name:MICAH
Last Name:QUALLE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:978 W ALLUVIAL AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-5502
Mailing Address - Country:US
Mailing Address - Phone:559-797-1614
Mailing Address - Fax:
Practice Address - Street 1:978 W ALLUVIAL AVE STE 107
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-5502
Practice Address - Country:US
Practice Address - Phone:559-797-1614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC53996106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist