MEDICARE: DR. HRYSSO KELLAS FERNBACH PSY. 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	103T00000X	Psychologist	2705	NJ
2	103TC0700X	Clinical Psychologist	9329	NY
3	103TC0700X	Clinical Psychologist	8643	FL
4	103TC0700X	Clinical Psychologist	26472	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2705	OTHER	NJ	PSYCHOLOGY LICENSE
2	PY8643	OTHER	FL	PSYCHOLOGY LICENSE
3	9329	OTHER	NY	PSYCHOLOGY LICENSE
4	26472	OTHER	CA	PSYCHOLOGY LICENSE

General Provider Information

NPI Number	:	1225232697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HRYSSO KELLAS FERNBACH PSY. D.

Provider Business Mailing Address
First Line	:	2668 W CANYON AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4684
Country	:	US
Telephone Number	:	732-770-5360
Fax Number	:

Provider Business Practice Location Address
First Line	:	2668 W CANYON AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4684
Country	:	US
Telephone Number	:	732-770-5360
Fax Number	:

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

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	09/12/2019

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Directions to “ DR. HRYSSO KELLAS FERNBACH PSY. D.” Practice Location

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