Healthcare Provider Details

I. General information

NPI: 1477692325
Provider Name (Legal Business Name): NATALIE HAGHANI FAGAN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 E GILBERT ST
SAN BERNARDINO CA
92415-5230
US

IV. Provider business mailing address

780 E GILBERT ST
SAN BERNARDINO CA
92415-1003
US

V. Phone/Fax

Practice location:
  • Phone: 909-387-7194
  • Fax: 909-387-7100
Mailing address:
  • Phone: 909-387-7194
  • Fax: 909-387-7100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT47535
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: