Healthcare Provider Details

I. General information

NPI: 1700083540
Provider Name (Legal Business Name): MEGHAN FAGUNDES M.S., M.A., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8765 AERO DR STE 228
SAN DIEGO CA
92123-1785
US

IV. Provider business mailing address

PO BOX 16753
SAN DIEGO CA
92176-6753
US

V. Phone/Fax

Practice location:
  • Phone: 858-876-7779
  • Fax: 619-272-7542
Mailing address:
  • Phone: 858-634-0456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53683
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY31947
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: