Healthcare Provider Details

I. General information

NPI: 1689031841
Provider Name (Legal Business Name): KYLE FRAGA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5904 ABERNATHY DR
RIVERSIDE CA
92507-6499
US

IV. Provider business mailing address

5904 ABERNATHY DR
RIVERSIDE CA
92507-6499
US

V. Phone/Fax

Practice location:
  • Phone: 951-237-9390
  • Fax:
Mailing address:
  • Phone: 951-237-9390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number69171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: