Provider Demographics
NPI:1841648185
Name:EDO-OKUONGHAE, FREDRICK (LMFT, PSYD)
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:
Last Name:EDO-OKUONGHAE
Suffix:
Gender:M
Credentials:LMFT, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13101 W WASHINGTON BLVD STE 245
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5173
Mailing Address - Country:US
Mailing Address - Phone:424-362-8745
Mailing Address - Fax:
Practice Address - Street 1:13101 W WASHINGTON BLVD STE 245
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5173
Practice Address - Country:US
Practice Address - Phone:424-362-8745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102L00000X
TX204222106H00000X
CA113359106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst