Provider Demographics
NPI:1396929923
Name:MB DUAL DIAGNOSIS
Entity type:Organization
Organization Name:MB DUAL DIAGNOSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MR
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:BECERRA
Authorized Official - Suffix:JR
Authorized Official - Credentials:BS
Authorized Official - Phone:559-352-2714
Mailing Address - Street 1:4782 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-0912
Mailing Address - Country:US
Mailing Address - Phone:559-352-2714
Mailing Address - Fax:
Practice Address - Street 1:302 E FOUNTAIN WAY
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-4619
Practice Address - Country:US
Practice Address - Phone:559-352-2714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA179679101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty