Provider Demographics
NPI:1376685974
Name:FORTUNE, JULIE MANCIA (MS)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:MANCIA
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:MANCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:2120 BELCOURT AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-3504
Mailing Address - Country:US
Mailing Address - Phone:615-936-0336
Mailing Address - Fax:615-936-0352
Practice Address - Street 1:1835 SUNNY CREST DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835
Practice Address - Country:US
Practice Address - Phone:714-446-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1227106H00000X
CAMFC 48831106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist