Provider Demographics
NPI:1912486424
Name:FOTINOS, DALLAS
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:
Last Name:FOTINOS
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 1:3027 FLEMING DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-3714
Mailing Address - Country:US
Mailing Address - Phone:858-442-6355
Mailing Address - Fax:
Practice Address - Street 1:3027 FLEMING DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92139-3714
Practice Address - Country:US
Practice Address - Phone:858-442-6355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7115101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional