Healthcare Provider Details

I. General information

NPI: 1225698590
Provider Name (Legal Business Name): NICOLE FAGUNDES AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 W FOOTHILL BLVD
UPLAND CA
91786-3768
US

IV. Provider business mailing address

1126 W FOOTHILL BLVD
UPLAND CA
91786-3768
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-0513
  • Fax:
Mailing address:
  • Phone: 909-985-0513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number113888
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: