Basic Information
| Provider Information | |||||||||
| NPI: | 1376685974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTUNE | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | MANCIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANCIA | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2120 BELCOURT AVE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372123504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159360336 | ||||||||
| FaxNumber: | 6159360352 | ||||||||
| Practice Location | |||||||||
| Address1: | 1835 SUNNY CREST DR | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144465101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1227 | TN | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | MFC 48831 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.