Healthcare Provider Details

I. General information

NPI: 1114411618
Provider Name (Legal Business Name): FOSS PSYCHOLOGICAL SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 S MARENGO AVE
PASADENA CA
91101-3113
US

IV. Provider business mailing address

1108 W AMERIGE AVE
FULLERTON CA
92833-2708
US

V. Phone/Fax

Practice location:
  • Phone: 626-840-5740
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28674
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT83193
License Number StateCA

VIII. Authorized Official

Name: JESSICA FOSS
Title or Position: PRESIDENT
Credential: PHD
Phone: 626-840-5740