Healthcare Provider Details

I. General information

NPI: 1952979098
Provider Name (Legal Business Name): MOE FATHI PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 FLETCHER PKWY STE 110
EL CAJON CA
92020-2117
US

IV. Provider business mailing address

1114 HAYES
IRVINE CA
92620-3766
US

V. Phone/Fax

Practice location:
  • Phone: 888-983-1531
  • Fax:
Mailing address:
  • Phone: 949-350-2773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSB94029025
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: