Healthcare Provider Details

I. General information

NPI: 1275813149
Provider Name (Legal Business Name): BONNIE JULIET FAGAN M.S., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S KRAEMER BLVD STE 130
PLACENTIA CA
92870-6100
US

IV. Provider business mailing address

PO BOX 512
PLACENTIA CA
92871-0512
US

V. Phone/Fax

Practice location:
  • Phone: 714-386-9809
  • Fax:
Mailing address:
  • Phone: 714-386-9809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number91055
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: