Healthcare Provider Details

I. General information

NPI: 1497817043
Provider Name (Legal Business Name): DANA FOGEL STARK LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19231 VICTORY BLVD STE 110
RESEDA CA
91335-6321
US

IV. Provider business mailing address

19231 VICTORY BLVD STE 110
RESEDA CA
91335-6321
US

V. Phone/Fax

Practice location:
  • Phone: 818-708-4500
  • Fax: 818-654-1956
Mailing address:
  • Phone: 818-708-4500
  • Fax: 818-654-1956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC39754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: