Provider Demographics
NPI:1386081743
Name:FRUCHTBAUM, IRENE S (PHD, QME)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:S
Last Name:FRUCHTBAUM
Suffix:
Gender:F
Credentials:PHD, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Mailing Address - Fax:
Practice Address - Street 1:22231 MULHOLLAND HWY
Practice Address - Street 2:SUITE 106
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-5123
Practice Address - Country:US
Practice Address - Phone:818-222-9300
Practice Address - Fax:818-223-8224
Is Sole Proprietor?:No
Enumeration Date:2013-05-25
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18821103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical