Healthcare Provider Details

I. General information

NPI: 1740959204
Provider Name (Legal Business Name): CAMERON MICHAEL FENTON AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 S BEACON ST
SAN PEDRO CA
90731-4324
US

IV. Provider business mailing address

1003 S BEACON ST
SAN PEDRO CA
90731-4324
US

V. Phone/Fax

Practice location:
  • Phone: 310-514-4940
  • Fax:
Mailing address:
  • Phone: 310-514-4940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164033
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberB001720024
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: