Provider Demographics
NPI:1083050207
Name:FRAGOSO, ROBERT (LMFT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FRAGOSO
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43520 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4089
Mailing Address - Country:US
Mailing Address - Phone:661-266-4783
Mailing Address - Fax:661-266-1210
Practice Address - Street 1:190 SIERRA CT STE C4
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7609
Practice Address - Country:US
Practice Address - Phone:661-418-9356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AMFT99212106H00000X
CA121957106H00000X
CA99212106H00000X
171M00000X
CALMFT121957106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL