Provider Demographics
NPI:1265896781
Name:FAGUNDES, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FAGUNDES
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 1:12440 FIRESTONE BLVD
Mailing Address - Street 2:SUITE 3020
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-4328
Mailing Address - Country:US
Mailing Address - Phone:562-864-7821
Mailing Address - Fax:562-864-7864
Practice Address - Street 1:982 MISSION ST FL 2
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2911
Practice Address - Country:US
Practice Address - Phone:415-597-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38331167G00000X
390200000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program