Healthcare Provider Details

I. General information

NPI: 1689702466
Provider Name (Legal Business Name): CAMILLE J FAGENSON L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MISSION ST
SAN MARINO CA
91108-1632
US

IV. Provider business mailing address

2400 MISSION ST
SAN MARINO CA
91108-1632
US

V. Phone/Fax

Practice location:
  • Phone: 626-403-8999
  • Fax: 626-403-8989
Mailing address:
  • Phone: 626-403-8999
  • Fax: 626-403-8989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS14489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: