Provider Demographics
NPI:1689804932
Name:FRY, JOHN S (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:FRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1300 BRISTOL ST N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2951
Mailing Address - Country:US
Mailing Address - Phone:949-863-1420
Mailing Address - Fax:949-722-0575
Practice Address - Street 1:1300 BRISTOL ST N
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2951
Practice Address - Country:US
Practice Address - Phone:949-863-1420
Practice Address - Fax:949-722-0575
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY3820103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical