Basic Information
| Provider Information | |||||||||
| NPI: | 1932586864 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRANSITIONAL AGE YOUTH EXPANSION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4441 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596009193 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4411 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596006853 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2015 | ||||||||
| LastUpdateDate: | 04/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | UTECHT | ||||||||
| AuthorizedOfficialFirstName: | DAWAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5596009193 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.