Provider Demographics
NPI:1982163226
Name:ISIDORO, MYTZY
Entity Type:Individual
Prefix:
First Name:MYTZY
Middle Name:
Last Name:ISIDORO
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 1:3433 W SHAW AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3229
Mailing Address - Country:US
Mailing Address - Phone:559-558-4051
Mailing Address - Fax:
Practice Address - Street 1:2416 W SHAW AVE STE 114
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3303
Practice Address - Country:US
Practice Address - Phone:559-374-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-16
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 106S00000X
CA12862101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician