Provider Demographics
NPI:1720736374
Name:HEALE, A PROFESSIONAL LICENSED CLINICAL SOCIAL WORK CORPORATION
Entity Type:Organization
Organization Name:HEALE, A PROFESSIONAL LICENSED CLINICAL SOCIAL WORK CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:D
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:209-450-8037
Mailing Address - Street 1:3848 MCHENRY AVE STE 135-123
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-1586
Mailing Address - Country:US
Mailing Address - Phone:209-450-8037
Mailing Address - Fax:
Practice Address - Street 1:420 DOWNEY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1301
Practice Address - Country:US
Practice Address - Phone:209-450-8037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700125705Medicaid
CA1346908167Medicaid