Healthcare Provider Details

I. General information

NPI: 1386081743
Provider Name (Legal Business Name): IRENE S FRUCHTBAUM PH.D., Q.M.E.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2013
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22231 MULHOLLAND HWY SUITE 106
CALABASAS CA
91302-5123
US

IV. Provider business mailing address

PO BOX 4117
WEST HILLS CA
91308-4117
US

V. Phone/Fax

Practice location:
  • Phone: 818-222-9300
  • Fax: 818-223-8224
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY18821
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: