Healthcare Provider Details

I. General information

NPI: 1710905344
Provider Name (Legal Business Name): MICHAEL FEDER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CAMINO DEL RIO S SUITE205
SAN DIEGO CA
92108-3717
US

IV. Provider business mailing address

2525 CAMINO DEL RIO SO. SUITE 205
SAN DIEGO CA
92108
US

V. Phone/Fax

Practice location:
  • Phone: 619-291-2511
  • Fax: 619-294-3012
Mailing address:
  • Phone: 619-291-2511
  • Fax: 619-294-3012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY6429
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY6429
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: