MEDICARE: DR. MARQUERITE C FAIRWEATHER MFC PSYCHOANALYST

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	103TP0814X	Psychoanalysis Psychologist	MFC12141	CA

General Provider Information

NPI Number	:	1326165309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARQUERITE C FAIRWEATHER MFC PSYCHOANALYST

Provider Business Mailing Address
First Line	:	26362 SANTA ROSA AVE
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-6218
Country	:	US
Telephone Number	:	949-831-0248
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 MAREBLU
Second Line	:	SUITE 240
City	:	ALISO VIEJO
State	:	CA
Zip	:	92656-3044
Country	:	US
Telephone Number	:	949-362-9479
Fax Number	:

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

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	07/08/2007

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