NPIMap

Organization Active NPI

Fullerton Counseling and Medical Group, Inc

  • Prescribing (Medical) Psychologist
  • Fullerton, CA
National Provider Identifier
1821131673
Registry record updated Mar 26, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Prescribing (Medical) PsychologistTaxonomy code 103TP0016X
License
C38832 Issued in CA
Legal business name
FULLERTON COUNSELING AND MEDICAL GROUP, INC
Practice address
2228 N State College Blvd
Fullerton, CA 92831-1361
Phone
(714) 990-0700
Fax
(714) 990-0142
NPI assigned
Feb 14, 2007
Last updated
Mar 26, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 26, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Justine Anne Petrie, M.D.NPI 1730264912
Title
President
Phone
(714) 990-0700

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 101YM0800X PSY6172 CA
Mental Health CounselorGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 101YM0800X PSY15282 CA
Prescribing (Medical) PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103TP0016X C38832 CA Primary
Marriage & Family TherapistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 106H00000X ML012201 CA

Addresses

Primary practice location

2228 N State College Blvd
Fullerton, CA 92831-1361

Mailing address

2228 N State College Blvd
Fullerton, CA 92831-1361
Phone (714) 990-0700

National Provider Directory

National Provider Directory

Locations

2228 N State College Blvd
Fullerton, CA 92831
Phone (714) 451-6205

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1171411200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1427328000000",
    "number": "1821131673",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2228 N STATE COLLEGE BLVD",
            "city": "FULLERTON",
            "state": "CA",
            "postal_code": "928311361",
            "telephone_number": "714-990-0700",
            "fax_number": "714-990-0142"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2228 N STATE COLLEGE BLVD",
            "city": "FULLERTON",
            "state": "CA",
            "postal_code": "928311361",
            "telephone_number": "714-990-0700",
            "fax_number": "714-990-0142"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FULLERTON COUNSELING AND MEDICAL GROUP, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-14",
        "last_updated": "2015-03-26",
        "status": "A",
        "authorized_official_last_name": "PETRIE",
        "authorized_official_first_name": "JUSTINE",
        "authorized_official_middle_name": "ANNE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "714-990-0700",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": "CA",
            "license": "PSY6172",
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": "CA",
            "license": "PSY15282",
            "primary": false
        },
        {
            "code": "103TP0016X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist, Prescribing (Medical)",
            "state": "CA",
            "license": "C38832",
            "primary": true
        },
        {
            "code": "106H00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Marriage & Family Therapist",
            "state": "CA",
            "license": "ML012201",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fullerton, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 26, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.