Healthcare Provider Details

I. General information

NPI: 1568538825
Provider Name (Legal Business Name): IREN FELLEGVARI PSY.D, MFT, CADCII,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5230 CARROLL CANYON RD STE 100
SAN DIEGO CA
92121-1778
US

IV. Provider business mailing address

4929 WILSHIRE BLVD 510
LOS ANGELES CA
90010-3820
US

V. Phone/Fax

Practice location:
  • Phone: 858-353-8088
  • Fax:
Mailing address:
  • Phone: 562-904-3999
  • Fax: 855-688-8746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRA855007
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLR300411
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number25047
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number46358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: