Healthcare Provider Details

I. General information

NPI: 1083097968
Provider Name (Legal Business Name): REGINA FAGOUT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2667 CAMINO DEL RIO S STE 301-1
SAN DIEGO CA
92108-3707
US

IV. Provider business mailing address

PO BOX 420295
SAN DIEGO CA
92142-0295
US

V. Phone/Fax

Practice location:
  • Phone: 858-761-4246
  • Fax:
Mailing address:
  • Phone: 858-761-4246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number76447
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number112511
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: