Basic Information
| Provider Information | |||||||||
| NPI: | 1851855910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUKUDA | ||||||||
| FirstName: | EMI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 HOMESTEAD PL # 1 | ||||||||
| Address2: | |||||||||
| City: | NEW ROCHELLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 108014307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143802352 | ||||||||
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| Practice Location | |||||||||
| Address1: | 731 MAIN ST STE 122 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064682872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032617090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2019 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 003650 | CT | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.