Provider Demographics
NPI:1053973164
Name:HART, FAWN I (AMFT)
Entity type:Individual
Prefix:
First Name:FAWN
Middle Name:I
Last Name:HART
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-8500
Mailing Address - Country:US
Mailing Address - Phone:055-876-9918
Mailing Address - Fax:
Practice Address - Street 1:500 AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-8500
Practice Address - Country:US
Practice Address - Phone:805-587-6991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT127976106H00000X, 101YM0800X
CA127976101YM0800X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner