Healthcare Provider Details

I. General information

NPI: 1588702740
Provider Name (Legal Business Name): JOHN FERGUS FAHY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK FAHY PH.D.

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 DWIGHT WAY 5 NORTH
BERKELEY CA
94704-2608
US

IV. Provider business mailing address

2001 DWIGHT WAY 5 NORTH
BERKELEY CA
94704-2608
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-4896
  • Fax: 510-204-4655
Mailing address:
  • Phone: 510-204-4896
  • Fax: 510-204-4655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPSY14056
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY14056
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY14056
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPSY14056
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: