Healthcare Provider Details

I. General information

NPI: 1760312037
Provider Name (Legal Business Name): KHALILAH NICOLE FORTENBERRY MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 MARSHALL DR
WALNUT CREEK CA
94598-4908
US

IV. Provider business mailing address

1145 61ST AVE
OAKLAND CA
94621-3913
US

V. Phone/Fax

Practice location:
  • Phone: 925-944-6828
  • Fax:
Mailing address:
  • Phone: 510-499-9374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number230198675
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: