Provider Demographics
NPI:1255636619
Name:FUCHINO, KELLY K (LCSW)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:K
Last Name:FUCHINO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 N EDGEMONT ST
Mailing Address - Street 2:SOCIAL MEDICINE, 1ST FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5209
Mailing Address - Country:US
Mailing Address - Phone:323-783-4371
Mailing Address - Fax:
Practice Address - Street 1:1505 N EDGEMONT ST
Practice Address - Street 2:1ST FLOOR, SOCIAL MEDICINE
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5209
Practice Address - Country:US
Practice Address - Phone:323-783-4371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-17
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS238531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical