Provider Demographics
NPI:1801302633
Name:FUKINO, OCTAVIA RUSU (LMFT #94660 LPCC#461)
Entity type:Individual
Prefix:MRS
First Name:OCTAVIA
Middle Name:RUSU
Last Name:FUKINO
Suffix:
Gender:F
Credentials:LMFT #94660 LPCC#461
Other - Prefix:MRS
Other - First Name:OCTAVIA
Other - Middle Name:
Other - Last Name:GAVRILA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7206 HAVENROCK DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-3006
Mailing Address - Country:US
Mailing Address - Phone:714-882-9811
Mailing Address - Fax:
Practice Address - Street 1:250 EL CAMINO REAL STE 206
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3656
Practice Address - Country:US
Practice Address - Phone:714-882-9811
Practice Address - Fax:714-882-9811
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT94660103TF0000X
CA4612103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily