Provider Demographics
NPI:1558558676
Name:FERNANDEZ, MANUEL ENRIQUE (PSYD, MSCP)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:ENRIQUE
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PSYD, MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 CONCORD AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-5608
Mailing Address - Country:US
Mailing Address - Phone:925-849-5349
Mailing Address - Fax:925-270-3382
Practice Address - Street 1:1070 CONCORD AVE STE 109
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5608
Practice Address - Country:US
Practice Address - Phone:925-849-5349
Practice Address - Fax:925-270-3382
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TP0016X, 283Q00000X
CAPSY 26787251S00000X, 282N00000X
CAPSY26787103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No251S00000XAgenciesCommunity/Behavioral Health
No282N00000XHospitalsGeneral Acute Care Hospital
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750641189OtherNPI