Basic Information
| Provider Information | |||||||||
| NPI: | 1124463716 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL CALIFORNIA WOMEN'S FACILITY, CDCR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2844 E VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937205327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596655531 | ||||||||
| FaxNumber: | 5596656438 | ||||||||
| Practice Location | |||||||||
| Address1: | 2844 E VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937205327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596655531 | ||||||||
| FaxNumber: | 5596656048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2013 | ||||||||
| LastUpdateDate: | 05/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | HER | ||||||||
| AuthorizedOfficialFirstName: | MYMEE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 5596655531 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | PSY22396 | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8004039 | 01 | CA | CDCR CREDENTIALS VERIFICATION UNIT | OTHER |