Provider Demographics
NPI:1821249871
Name:FRAGUELA, MIGUEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:
Last Name:FRAGUELA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3128 O ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-6538
Mailing Address - Country:US
Mailing Address - Phone:916-330-4330
Mailing Address - Fax:916-330-4330
Practice Address - Street 1:3128 O ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6538
Practice Address - Country:US
Practice Address - Phone:916-330-4330
Practice Address - Fax:916-330-4330
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24240103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist