Basic Information
| Provider Information | |||||||||
| NPI: | 1083050207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRAGOSO | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43520 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935354089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612664783 | ||||||||
| FaxNumber: | 6612661210 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 SIERRA CT STE C4 | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935507609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614189356 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2013 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | AMFT99212 | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 121957 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 99212 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 106H00000X | LMFT121957 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 95-2633765 | 01 | CA | MEDI-CAL | OTHER |