Provider Demographics
NPI:1972193134
Name:FUAD, ANTHONY JOHN
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JOHN
Last Name:FUAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 ARD EEVIN AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-1223
Mailing Address - Country:US
Mailing Address - Phone:818-636-5471
Mailing Address - Fax:
Practice Address - Street 1:1635 ARD EEVIN AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-1223
Practice Address - Country:US
Practice Address - Phone:818-636-5471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170129828101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty