Provider Demographics
NPI:1164277869
Name:FORTENBERRY, KHALIL CEDRIC (AMFT)
Entity Type:Individual
Prefix:
First Name:KHALIL
Middle Name:CEDRIC
Last Name:FORTENBERRY
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-3913
Mailing Address - Country:US
Mailing Address - Phone:510-289-7339
Mailing Address - Fax:
Practice Address - Street 1:39159 PASEO PADRE PKWY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1608
Practice Address - Country:US
Practice Address - Phone:510-952-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132001101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health