Provider Demographics
NPI:1649320573
Name:FRY, ORVIN C (MA)
Entity type:Individual
Prefix:MR
First Name:ORVIN
Middle Name:C
Last Name:FRY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 913
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-0913
Mailing Address - Country:US
Mailing Address - Phone:530-273-0902
Mailing Address - Fax:530-273-7018
Practice Address - Street 1:13722 CRAWFORD LN
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9013
Practice Address - Country:US
Practice Address - Phone:530-273-0902
Practice Address - Fax:530-273-7018
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 21406106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist