Provider Demographics
NPI:1497496426
Name:UTOMO, MEGAN
Entity Type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:
Last Name:UTOMO
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 1:698 S FILLMORE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-6808
Mailing Address - Country:US
Mailing Address - Phone:818-805-4050
Mailing Address - Fax:
Practice Address - Street 1:5369 INGLEWOOD BLVD APT 3
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-5956
Practice Address - Country:US
Practice Address - Phone:833-831-8946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician