Provider Demographics
NPI:1669837761
Name:FUGATE, DIONNE
Entity Type:Individual
Prefix:
First Name:DIONNE
Middle Name:
Last Name:FUGATE
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 1:2400 W 134TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3606
Mailing Address - Country:US
Mailing Address - Phone:310-920-9695
Mailing Address - Fax:
Practice Address - Street 1:901 N PACIFIC COAST HWY STE 200A
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-7702
Practice Address - Country:US
Practice Address - Phone:310-316-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89877101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health