Provider Demographics
NPI:1730488180
Name:PROMESA BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:PROMESA BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIGANT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:559-439-5437
Mailing Address - Street 1:7475 N PALM AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-5763
Mailing Address - Country:US
Mailing Address - Phone:559-439-5437
Mailing Address - Fax:559-439-5411
Practice Address - Street 1:1258 E. BELMONT AVENUE
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:CA
Practice Address - Zip Code:93640
Practice Address - Country:US
Practice Address - Phone:559-655-4301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101044251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101044Medicaid