Healthcare Provider Details

I. General information

NPI: 1265896781
Provider Name (Legal Business Name): STEPHANIE FAGUNDES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 MISSION ST FL 2
SAN FRANCISCO CA
94103-2911
US

IV. Provider business mailing address

12440 FIRESTONE BLVD SUITE 3020
NORWALK CA
90650-4328
US

V. Phone/Fax

Practice location:
  • Phone: 415-597-8000
  • Fax:
Mailing address:
  • Phone: 562-864-7821
  • Fax: 562-864-7864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT38331
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: