Healthcare Provider Details

I. General information

NPI: 1801302633
Provider Name (Legal Business Name): OCTAVIA RUSU FUKINO LMFT #94660 LPCC#461
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. OCTAVIA GAVRILA

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 EL CAMINO REAL STE 206
TUSTIN CA
92780-3656
US

IV. Provider business mailing address

7206 HAVENROCK DR
HUNTINGTON BEACH CA
92648-3006
US

V. Phone/Fax

Practice location:
  • Phone: 714-882-9811
  • Fax: 714-882-9811
Mailing address:
  • Phone: 714-882-9811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4612
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberLMFT94660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: