Provider Demographics
NPI:1447010053
Name:IRENE S. FRUCHTBAUM, PH.D., Q.M.E.
Entity type:Organization
Organization Name:IRENE S. FRUCHTBAUM, PH.D., Q.M.E.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRUCHTBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, QME
Authorized Official - Phone:818-650-1960
Mailing Address - Street 1:PO BOX 4117
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91308-4117
Mailing Address - Country:US
Mailing Address - Phone:310-699-6510
Mailing Address - Fax:
Practice Address - Street 1:28310 ROADSIDE DR STE 202A
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4958
Practice Address - Country:US
Practice Address - Phone:818-650-1960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty