Provider Demographics
NPI:1417608068
Name:FAWCETT PSYCHOLOGY, INC.
Entity Type:Organization
Organization Name:FAWCETT PSYCHOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:619-306-0811
Mailing Address - Street 1:4625 SANTA MONICA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-2907
Mailing Address - Country:US
Mailing Address - Phone:619-306-0811
Mailing Address - Fax:
Practice Address - Street 1:3604 4TH AVE STE 5
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4118
Practice Address - Country:US
Practice Address - Phone:619-356-0811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty