MEDICARE: DR. CHRISTINE MARIE FAHRENBACH PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY 14736	CA

General Provider Information

NPI Number	:	1013021104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHRISTINE MARIE FAHRENBACH PH.D.

Provider Business Mailing Address
First Line	:	725 FRONT ST STE 200
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-4538
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	725 FRONT ST
Second Line	:	STE 200
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-4538
Country	:	US
Telephone Number	:	831-457-6601
Fax Number	:	831-459-7504

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	09/20/2012

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