Provider Demographics
NPI:1073056362
Name:PARACUELLOS, FABRICE (MFT)
Entity Type:Individual
Prefix:
First Name:FABRICE
Middle Name:
Last Name:PARACUELLOS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 BROADWAY ST STE 104.71
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1816
Mailing Address - Country:US
Mailing Address - Phone:949-682-9305
Mailing Address - Fax:
Practice Address - Street 1:303 BROADWAY ST STE 104.71
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-1816
Practice Address - Country:US
Practice Address - Phone:949-682-9305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-18
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT114054106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALMFT114054OtherLICENSED MARRIAGE AND FAMILY THERAPIST