Provider Demographics
NPI:1639553159
Name:MEZA-ACTIS, DESIREE SHARDEE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:SHARDEE
Last Name:MEZA-ACTIS
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 1:661 ROBERTS LN STE B
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93308-4723
Mailing Address - Country:US
Mailing Address - Phone:616-393-5836
Mailing Address - Fax:
Practice Address - Street 1:661 ROBERTS LN STE B
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-4723
Practice Address - Country:US
Practice Address - Phone:661-393-5836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 97462106H00000X
390200000X
CALMFT117304106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program