Healthcare Provider Details

I. General information

NPI: 1558558676
Provider Name (Legal Business Name): MANUEL ENRIQUE FERNANDEZ PSYD, MSCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 CONCORD AVE STE 109
CONCORD CA
94520-5608
US

IV. Provider business mailing address

1070 CONCORD AVE STE 109
CONCORD CA
94520-5608
US

V. Phone/Fax

Practice location:
  • Phone: 925-849-5349
  • Fax: 925-270-3382
Mailing address:
  • Phone: 925-849-5349
  • Fax: 925-270-3382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPSY 26787
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberPSY 26787
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY26787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: