Provider Demographics
NPI:1669984597
Name:DEWALT, DEBBIE J
Entity type:Individual
Prefix:
First Name:DEBBIE
Middle Name:J
Last Name:DEWALT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:
Other - Last Name:DEWALT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1328 E SWIFT AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-3928
Mailing Address - Country:US
Mailing Address - Phone:209-304-0814
Mailing Address - Fax:
Practice Address - Street 1:2772 S MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706
Practice Address - Country:US
Practice Address - Phone:559-265-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1268071017101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)