Provider Demographics
NPI:1861953408
Name:FOMIN, CHELSEA NATY
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:NATY
Last Name:FOMIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 E COLORADO BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 VERDANT ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1325
Practice Address - Country:US
Practice Address - Phone:323-536-2203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2024-09-24
Deactivation Date:2024-08-25
Deactivation Code:
Reactivation Date:2024-09-24
Provider Licenses
StateLicense IDTaxonomies
CALMFT142757106H00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician