Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | PSY14056 | CA |
N | 103TC0700X | Clinical Psychologist | PSY14056 | CA |
N | 102L00000X | Psychologist | PSY14056 | CA |
N | 103T00000X | Psychologist | PSY14056 | CA |
N | 103TP2701X | Group Psychotherapist | PSY14056 | CA |
N | 103TR0400X | Rehabilitation Psychologist | PSY14056 | CA |
NPI | 1588702740 |
---|---|
Provider Name | Mr. John Fergus Fahy |
First Address | Berkeley, CA 94704-2608 |
Second Address | Berkeley, CA 94704-2608 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2007 |
Last Update Date | 08/07/2007 |