Provider Demographics
NPI:1649626557
Name:COURTEAU-FONKALSRUD, PATRICE ISABEL (LMFT)
Entity type:Individual
Prefix:MS
First Name:PATRICE
Middle Name:ISABEL
Last Name:COURTEAU-FONKALSRUD
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 DOVE ST
Mailing Address - Street 2:SUITE 280
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2840
Mailing Address - Country:US
Mailing Address - Phone:949-525-7375
Mailing Address - Fax:949-200-9086
Practice Address - Street 1:1151 DOVE ST
Practice Address - Street 2:SUITE 280
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2840
Practice Address - Country:US
Practice Address - Phone:949-525-7375
Practice Address - Fax:949-200-9086
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT 33329106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist