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General NPI Number Information
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NPI Number | 1821131673
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Entity Type | Organization
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Legal Business Name | FULLERTON COUNSELING AND MEDICAL GROUP, INC
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Dates
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Enumeration Date | 02/14/2007
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Last Update Date | 03/26/2015
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Provider Practice Location Address
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Address Line | 2228 N STATE COLLEGE BLVD
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City | FULLERTON
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State | CA
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Zip | 92831-1361
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Country | US
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Telephone | 714-990-0700
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Fax | 714-990-0142
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Provider Business Mailing Address
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Address Line | 2228 N STATE COLLEGE BLVD
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City | FULLERTON
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State | CA
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Zip | 92831-1361
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Country | US
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Telephone | 714-990-0700
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Fax | 714-990-0142
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Authorized Official
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Title or Position | PRESIDENT
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Name | JUSTINE ANNE PETRIE
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Credential | M.D.
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Telephone | 714-990-0700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PSY6172
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PSY15282
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | ML012201
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 103TP0016X
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Taxonomy Name | Prescribing (Medical) Psychologist
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License Number | C38832
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License Number State | CA
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