Provider Demographics
NPI:1760865463
Name:PERSON, IRIS (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:IRIS
Middle Name:
Last Name:PERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3722
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93613-3722
Mailing Address - Country:US
Mailing Address - Phone:559-765-9644
Mailing Address - Fax:559-299-9985
Practice Address - Street 1:1600 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3212
Practice Address - Country:US
Practice Address - Phone:559-765-9644
Practice Address - Fax:559-299-9985
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66798101YM0800X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist