Provider Demographics
NPI:1881185502
Name:FRAGOSO, IRMA
Entity type:Individual
Prefix:
First Name:IRMA
Middle Name:
Last Name:FRAGOSO
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 1:110 W. 6TH ST.
Mailing Address - Street 2:P.O. BOX #815
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-1547
Mailing Address - Country:US
Mailing Address - Phone:626-485-6598
Mailing Address - Fax:
Practice Address - Street 1:2601 E CHAPMAN AVE STE 111
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3737
Practice Address - Country:US
Practice Address - Phone:626-671-5035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101801106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist