Basic Information
| Provider Information | |||||||||
| NPI: | 1467099465 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHIGBOLU | ||||||||
| FirstName: | FATIMA | ||||||||
| MiddleName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16587 WING LN | ||||||||
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| City: | LA PUENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917444154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237185094 | ||||||||
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| Practice Location | |||||||||
| Address1: | 508 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917233012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269748123 | ||||||||
| FaxNumber: | 6269748198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2019 | ||||||||
| LastUpdateDate: | 12/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/09/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 115560 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.