Provider Demographics
NPI:1952181190
Name:FENSKE, MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:FENSKE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N SAN DIMAS CANYON RD UNIT B217
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2789
Mailing Address - Country:US
Mailing Address - Phone:661-317-5051
Mailing Address - Fax:
Practice Address - Street 1:200 E DEL MAR BLVD STE 206
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2552
Practice Address - Country:US
Practice Address - Phone:661-317-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY34399103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist