Provider Demographics
NPI:1225160021
Name:DAGENAIS, DEBORAH JEAN
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEAN
Last Name:DAGENAIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SYCAMORE CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1220
Mailing Address - Country:US
Mailing Address - Phone:909-599-2694
Mailing Address - Fax:
Practice Address - Street 1:1900 SYCAMORE CANYON RD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1220
Practice Address - Country:US
Practice Address - Phone:909-599-2694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT44366106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist