Provider Demographics
NPI:1922401769
Name:MAKELY, TAMMIE SUE
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:SUE
Last Name:MAKELY
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 1:2540 W SHAW LN STE 107
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2700
Mailing Address - Country:US
Mailing Address - Phone:559-256-7666
Mailing Address - Fax:
Practice Address - Street 1:550 W ALLUVIAL AVE STE 108
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-5857
Practice Address - Country:US
Practice Address - Phone:559-761-9724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75056106H00000X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922401769Medicaid