Basic Information
| Provider Information | |||||||||
| NPI: | 1962777904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TELLEZ FONSECA | ||||||||
| FirstName: | IXCHEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TELLEZ DE LAMKIN | ||||||||
| OtherFirstName: | IXCHEL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 155 N RIVERVIEW DR # 112 | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928081225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145532372 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 CABRILLO PARK DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927015017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149534455 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2012 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 69229 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.