Provider Demographics
NPI:1295936771
Name:GARY S. CANNYON PSYCHOLOGICAL SERVICE CENTER
Entity type:Organization
Organization Name:GARY S. CANNYON PSYCHOLOGICAL SERVICE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PSY16998
Authorized Official - Phone:559-253-2260
Mailing Address - Street 1:5130 E CLINTON WAY
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-2014
Mailing Address - Country:US
Mailing Address - Phone:559-253-2277
Mailing Address - Fax:
Practice Address - Street 1:5130 E CLINTON WAY
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-2014
Practice Address - Country:US
Practice Address - Phone:559-253-2277
Practice Address - Fax:559-253-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16998103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty