Provider Demographics
NPI:1275813149
Name:FAGAN, BONNIE JULIET (MS, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:JULIET
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 512
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92871-0512
Mailing Address - Country:US
Mailing Address - Phone:714-386-9809
Mailing Address - Fax:
Practice Address - Street 1:101 S KRAEMER BLVD STE 130
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6100
Practice Address - Country:US
Practice Address - Phone:714-386-9809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA91055106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health