Provider Demographics
NPI:1447884382
Name:CASANOVA, ROGER (EDS)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:CASANOVA
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13749 E BULAH AVE
Mailing Address - Street 2:
Mailing Address - City:PARLIER
Mailing Address - State:CA
Mailing Address - Zip Code:93648-2831
Mailing Address - Country:US
Mailing Address - Phone:559-643-7717
Mailing Address - Fax:
Practice Address - Street 1:1976 MORRIS KYLE DR
Practice Address - Street 2:
Practice Address - City:FIREBAUGH
Practice Address - State:CA
Practice Address - Zip Code:93622-9711
Practice Address - Country:US
Practice Address - Phone:559-659-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-01
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
52423103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool