Provider Demographics
NPI:1548603368
Name:HARLAN, FREDRICK W JR
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:W
Last Name:HARLAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E HILLCREST DR STE 195
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-7795
Mailing Address - Country:US
Mailing Address - Phone:805-990-0578
Mailing Address - Fax:805-374-7707
Practice Address - Street 1:325 E HILLCREST DR STE 195
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7795
Practice Address - Country:US
Practice Address - Phone:805-990-0578
Practice Address - Fax:805-374-7707
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112234106H00000X
CAIMF 74125106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist