Provider Demographics
NPI:1225232697
Name:FERNBACH, HRYSSO KELLAS (PSY D)
Entity Type:Individual
Prefix:DR
First Name:HRYSSO
Middle Name:KELLAS
Last Name:FERNBACH
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2668 W CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4684
Mailing Address - Country:US
Mailing Address - Phone:732-770-5360
Mailing Address - Fax:
Practice Address - Street 1:2668 W CANYON AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4684
Practice Address - Country:US
Practice Address - Phone:732-770-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2705103T00000X
NY9329103TC0700X
FL8643103TC0700X
CA26472103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2705OtherPSYCHOLOGY LICENSE
FLPY8643OtherPSYCHOLOGY LICENSE
NY9329OtherPSYCHOLOGY LICENSE
CA26472OtherPSYCHOLOGY LICENSE