Provider Demographics
NPI:1952717019
Name:SIMBOLON, FETRIC
Entity Type:Individual
Prefix:
First Name:FETRIC
Middle Name:
Last Name:SIMBOLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 DAVIDSON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1711
Mailing Address - Country:US
Mailing Address - Phone:909-630-8084
Mailing Address - Fax:
Practice Address - Street 1:1714 DAVIDSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-1711
Practice Address - Country:US
Practice Address - Phone:909-630-8084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 34823103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst