Provider Demographics
NPI:1790967453
Name:FRESNO STATE UNIVERSITY HEALTH AND PSYCHOLOGICAL SERVICEDS
Entity Type:Organization
Organization Name:FRESNO STATE UNIVERSITY HEALTH AND PSYCHOLOGICAL SERVICEDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:RUTHRAUFF
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:559-278-6717
Mailing Address - Street 1:UNIVERSITY HEALTH AND PSYCHOLOGICAL SERVICES
Mailing Address - Street 2:5044 NORTH BARTON AVENUE M/S HC81
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93740-0001
Mailing Address - Country:US
Mailing Address - Phone:559-278-6715
Mailing Address - Fax:559-278-5409
Practice Address - Street 1:UNIVERSITY HEALTH AND PSYCHOLOGICAL SERVICES
Practice Address - Street 2:5044 NORTH BARTON AVENUE M/S HC81
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93740-0001
Practice Address - Country:US
Practice Address - Phone:559-278-6715
Practice Address - Fax:559-278-5409
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALIFORNIA STATE UNIVERSITY FRESNO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health