Provider Demographics
NPI:1619194347
Name:RADELLANT, CHARMAINE
Entity Type:Individual
Prefix:DR
First Name:CHARMAINE
Middle Name:
Last Name:RADELLANT
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:POST OFFICE BOX 842
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93712
Mailing Address - Country:US
Mailing Address - Phone:559-307-9505
Mailing Address - Fax:
Practice Address - Street 1:4025 N FRESNO ST STE 102
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-4027
Practice Address - Country:US
Practice Address - Phone:559-307-9505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22964103TA0700X, 103TC2200X, 103TF0200X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy